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...one group — middle-age whites in the United States — constitutes an alarming trend. They are dying in increasing numbers...

The main causes of death are as striking as the fact itself: suicide, alcoholism, and overdoses of prescription and illegal drugs. “People seem to be killing themselves, slowly or quickly,” Deaton told me. The circumstances are usually caused by stress, depression and despair. The only comparable spike in deaths in an industrialized country took place among Russian males after the collapse of the Soviet Union, when rates of alcoholism skyrocketed...

The United States is going through a great power shift. Working-class whites don’t think of themselves as an elite group. But, in a sense, they have been, certainly compared with blacks, Hispanics, Native Americans and most immigrants. They were central to America’s economy, its society, indeed its very identity. They are not anymore. Donald Trump has promised that he will change this and make them win again. But he can’t. No one can. And deep down, they know it.

"Citing a study that shows Middle American whites are dying in increasing numbers, like a twisted and bitter eugenicist, serial-plagiarist Fareed Zakaria doesn’t even attempt to contain his glee. By painting those who are supposedly dying as useless, drug-addicted ragers, he paints a picture of a weak, angry, and ultimately stupid ethnic group getting what it deserves...Why is Middle America killing itself? The fact itself is probably the most important social science finding in years. It is already reshaping American politics. The Post’s Jeff Guo notes that the people who make up this cohort are “largely responsible for Donald Trump’s lead in the race for the Republican nomination for president.”"

"Now we know, thanks to a new paper from the Nobel laureate Angus Deaton and his wife, Anne Case. And their findings, inevitably, are the latest ideological Rorschach test in the debate over how to save the American working class."

"“This is the first indicator that the plane has crashed,” said Jonathan Skinner, a professor of economics at Dartmouth College, who reviewed the study and co-authored a commentary that appears with it. “I don’t know what’s going on, but the plane has definitely crashed...

“I think it has to have something to do [with] the pain underlying it,” both physical and psychic, he said. “That is the age when people have their midlife crisis . . . I think it has to do with that stage of life, and physical ailments do start to accumulate at that age.

“This paper really is a question, not an answer,” he added.

The proportion of people who said they were in “serious psychological distress” also rose significantly, the research shows...

A study in the journal JAMA Psychiatry last year reported that 90 percent of the people who tried heroin for the first time in the last decade were white. Three-quarters said they were introduced to heroin through the use of prescription drugs."

"The end of the American dream? With the disappearance of stable jobs in manufacturing and construction over the years, many people with only a high school education may not have as many opportunities as they may have had a generation ago. Surveys have shown that about half of middle-aged Americans have not been able to save enough money for retirement. Many in this generation are "the first to find, in midlife, that they will not be better off than their parents," the authors wrote."

"Demographics and the Nature of Future ConflictCurrent demographic trends will affect the nature and conduct of future armed conflicts by influencing the physical environment of future conflicts, and by creating new strategic instruments of conflict... Demographic shifts can cause conflict in two major ways: by directly causing increased tensions between states in a region, or by altering the domestic politics of a given state so that it becomes a security problem for its neighbors.M.N.: Or ceases "to become a security problem" for other states.Security implications of population movements: Refugee (and sometimes migrant) flows can result in security problems for either the home or the host country.[21] The home country faces the risk that the departed refugees will use the host nation as a springboard to mount political or military actions aimed at weakening or overthrowing the government of the home nation. Refugee groups could even play a role in changing the policy of the host nation so that it becomes an enemy of the home nation. Demographics and Domestic PoliticsNow that we have examined how demographic factors could change warfare and affect regional security, it is important to assess how demographic factors might affect the political nature of states and hence their foreign policies. Demographic shifts can affect domestic politics in four ways: the creation of revolutionary states, the creation of failed states, the outbreak of ethnic warfare, and the ecological marginalization of poorer socioeconomic groups. Ethnic conflict. In states with ethnically intermixed patterns of population settlement, any significant loss of central government legitimacy or control, when coupled with the existence of nationalist history among one or more of the ethnic groups involved, can provide the spark needed to ignite a violent conflagration. Intermixed patterns of settlement contain within them an inherently greater risk of conflict than do situations in which a minority ethnic group is clearly concentrated within a well-defined geographical area. If central government authority begins to weaken in states with ethnically intermixed settlement patterns, there is a risk that the "security dilemma" may kick in."

A report by the U.S. Census Bureau projects a decrease in the ratio of Whites between 2010 and 2050, from 79.5% to 74.0%.[60] At the same time, Non-Hispanic Whites are projected to no longer make up a majority of the population by 2042, but will remain the largest single ethnic group. In 2050 they will compose 46.3% of the population. Non-Hispanic whites made up 85% of the population in 1960.[61]

The report foresees the Hispanic or Latino population rising from 16% today to 30% by 2050, the Black percentage barely rising from 12.9% to 13.1%, and Asian Americans upping their 4.6% share to 7.8%. The United States had a population of 310 million people in October 2010, and is projected to reach 400 million by 2039 and 439 million in 2050.[20][62][63][64] It is further projected that 82% of the increase in population from 2005 to 2050 will be due to immigrants and their children.[65]

Doctrine
The Foundations of Geopolitics, initially published in 1997 when Vladimir Putin became FSB chief, is a military training textbook which has influenced key Russian decision-makers. It states that Russia should use its special forces within the borders of the United States to:[2]
introduce geopolitical disorder into internal American activity, encouraging all kinds of separatism and ethnic, social and racial conflicts, actively supporting all dissident movements – extremist, racist, and sectarian groups, thus destabilizing internal political processes in the U.S. It would also make sense simultaneously to support isolationist tendencies in American politics.

"As the weeks turned into months turned into years, some of the effects of 9/11 could be felt long after the initial destruction. They weren’t always physical effects either — many people suffered from mental health problems such as post-traumatic stress disorder (PTSD) for years after.About a year ago, a research study examined some of these effects. Here’s what they found.The study was conducted by Perlman et al.1 and looked at all of the health and psychology research literature in PubMed related to the 9/11 attacks. The researchers found more than 150 studies looking at the mental health effects alone.While the attacks occurred in two specific geographical areas in the U.S., the entire U.S. population felt the impact of the attacks..."

Contributed by Angus Deaton, September 17, 2015 (sent for review August 22, 2015; reviewed by David Cutler, Jon Skinner, and David Weir)

Significance

Midlife increases in suicides and drug poisonings have been previously noted. However, that these upward trends were persistent and large enough to drive up all-cause midlife mortality has, to our knowledge, been overlooked. If the white mortality rate for ages 45−54 had held at their 1998 value, 96,000 deaths would have been avoided from 1999–2013, 7,000 in 2013 alone. If it had continued to decline at its previous (1979‒1998) rate, half a million deaths would have been avoided in the period 1999‒2013, comparable to lives lost in the US AIDS epidemic through mid-2015. Concurrent declines in self-reported health, mental health, and ability to work, increased reports of pain, and deteriorating measures of liver function all point to increasing midlife distress.

Abstract

This paper documents a marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women in the United States between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround. The midlife mortality reversal was confined to white non-Hispanics; black non-Hispanics and Hispanics at midlife, and those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall. This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Although all education groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, those with less education saw the most marked increases. Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population. We comment on potential economic causes and consequences of this deterioration.

There has been a remarkable long-term decline in mortality rates in the United States, a decline in which middle-aged and older adults have fully participated (1⇓‒3). Between 1970 and 2013, a combination of behavioral change, prevention, and treatment (4, 5) brought down mortality rates for those aged 45–54 by 44%. Parallel improvements were seen in other rich countries (2). Improvements in health also brought declines in morbidity, even among the increasingly long-lived elderly (6⇓⇓‒9).

These reductions in mortality and morbidity have made lives longer and better, and there is a general and well-based presumption that these improvements will continue. This paper raises questions about that presumption for white Americans in midlife, even as mortality and morbidity continue to fall among the elderly.

This paper documents a marked deterioration in the morbidity and mortality of middle-aged white non-Hispanics in the United States after 1998. General deterioration in midlife morbidity among whites has received limited comment (10, 11), but the increase in all-cause midlife mortality that we describe has not been previously highlighted. For example, it does not appear in the regular mortality and health reports issued by the CDC (12), perhaps because its documentation requires disaggregation by age and race. Beyond that, the extent to which the episode is unusual requires historical context, as well as comparison with other rich countries over the same period.

Increasing mortality in middle-aged whites was matched by increasing morbidity. When seen side by side with the mortality increase, declines in self-reported health and mental health, increased reports of pain, and greater difficulties with daily living show increasing distress among whites in midlife after the late 1990s. We comment on potential economic causes and consequences of this deterioration.

Midlife Mortality

Fig. 1 shows age 45–54 mortality rates for US white non-Hispanics (USW, in red), US Hispanics (USH, in blue), and six rich industrialized comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada (CAN), Australia (AUS), and Sweden (SWE). The comparison is similar for other Organisation for Economic Co-operation and Development countries.

Fig. 1 shows a cessation and reversal of the decline in midlife mortality for US white non-Hispanics after 1998. From 1978 to 1998, the mortality rate for US whites aged 45–54 fell by 2% per year on average, which matched the average rate of decline in the six countries shown, and the average over all other industrialized countries. After 1998, other rich countries’ mortality rates continued to decline by 2% a year. In contrast, US white non-Hispanic mortality rose by half a percent a year. No other rich country saw a similar turnaround. The mortality reversal was confined to white non-Hispanics; Hispanic Americans had mortality declines indistinguishable from the British (1.8% per year), and black non-Hispanic mortality for ages 45–54 declined by 2.6% per year over the period.

For deaths before 1989, information on Hispanic origin is not available, but we can calculate lives lost among all whites. For those aged 45–54, if the white mortality rate had held at its 1998 value, 96,000 deaths would have been avoided from 1999 to 2013, 7,000 in 2013 alone. If it had continued to fall at its previous (1979‒1998) rate of decline of 1.8% per year, 488,500 deaths would have been avoided in the period 1999‒2013, 54,000 in 2013. (Supporting Information provides details on calculations.)

This turnaround, as of 2014, is specific to midlife. All-cause mortality rates for white non-Hispanics aged 65–74 continued to fall at 2% per year from 1999 to 2013; there were similar declines in all other racial and ethnic groups aged 65–74. However, the mortality decline for white non-Hispanics aged 55–59 also slowed, declining only 0.5% per year over this period.

There was a pause in midlife mortality decline in the 1960s, largely explicable by historical patterns of smoking (13). Otherwise, the post-1999 episode in midlife mortality in the United States is both historically and geographically unique, at least since 1950. The turnaround is not a simple cohort effect; Americans born between 1945 and 1965 did not have particularly high mortality rates before midlife.

Fig. 2 presents the three causes of death that account for the mortality reversal among white non-Hispanics, namely suicide, drug and alcohol poisoning (accidental and intent undetermined), and chronic liver diseases and cirrhosis. All three increased year-on-year after 1998. Midlife increases in suicides and drug poisonings have been previously noted (14⇓–16). However, that these upward trends were persistent and large enough to drive up all-cause midlife mortality has, to our knowledge, been overlooked. For context, Fig. 2 also presents mortality from lung cancer and diabetes. The obesity epidemic has (rightly) made diabetes a major concern for midlife Americans; yet, in recent history, death from diabetes has not been an increasing threat. Poisonings overtook lung cancer as a cause of death in 2011 in this age group; suicide appears poised to do so.

Fig. 2.

Mortality by cause, white non-Hispanics ages 45–54.

Table 1 shows changes in mortality rates from 1999 to 2013 for white non-Hispanic men and women ages 45–54 and, for comparison, changes for black non-Hispanics and for Hispanics. The table also presents changes in mortality rates for white non-Hispanics by three broad education groups: those with a high school degree or less (37% of this subpopulation over this period), those with some college, but no bachelor’s (BA) degree (31%), and those with a BA or more (32%). The fraction of 45- to 54-y-olds in the three education groups was stable over this period. Each cell shows the change in the mortality rate from 1999 to 2013, as well as its level (deaths per 100,000) in 2013.

Over the 15-y period, midlife all-cause mortality fell by more than 200 per 100,000 for black non-Hispanics, and by more than 60 per 100,000 for Hispanics. By contrast, white non-Hispanic mortality rose by 34 per 100,000. The ratio of black non-Hispanic to white non-Hispanic mortality rates for ages 45–54 fell from 2.09 in 1999 to 1.40 in 2013. CDC reports have highlighted the narrowing of the black−white gap in life expectancy (12). However, for ages 45–54, the narrowing of the mortality rate ratio in this period was largely driven by increased white mortality; if white non-Hispanic mortality had continued to decline at 1.8% per year, the ratio in 2013 would have been 1.97. The role played by changing white mortality rates in the narrowing of the black−white life expectancy gap (2003−2008) has been previously noted (17). It is far from clear that progress in black longevity should be benchmarked against US whites.

The change in all-cause mortality for white non-Hispanics 45–54 is largely accounted for by an increasing death rate from external causes, mostly increases in drug and alcohol poisonings and in suicide. (Patterns are similar for men and women when analyzed separately.) In contrast to earlier years, drug overdoses were not concentrated among minorities. In 1999, poisoning mortality for ages 45–54 was 10.2 per 100,000 higher for black non-Hispanics than white non-Hispanics; by 2013, poisoning mortality was 8.4 per 100,000 higher for whites. Death from cirrhosis and chronic liver diseases fell for blacks and rose for whites. After 2006, death rates from alcohol- and drug-induced causes for white non-Hispanics exceeded those for black non-Hispanics; in 2013, rates for white non-Hispanic exceeded those for black non-Hispanics by 19 per 100,000.

The three numbered rows of Table 1 show that the turnaround in mortality for white non-Hispanics was driven primarily by increasing death rates for those with a high school degree or less. All-cause mortality for this group increased by 134 per 100,000 between 1999 and 2013. Those with college education less than a BA saw little change in all-cause mortality over this period; those with a BA or more education saw death rates fall by 57 per 100,000. Although all three educational groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, increases were largest for those with the least education. The mortality rate from poisonings rose more than fourfold for this group, from 13.7 to 58.0, and mortality from chronic liver diseases and cirrhosis rose by 50%. The final two rows of the table show increasing educational gradients from 1999 and 2013; the ratio of midlife all-cause mortality of the lowest to the highest educational group rose from 2.6 in 1999 to 4.1 in 2013.

Fig. 3 shows the temporal and spatial joint evolution of suicide and poisoning mortality for white non-Hispanics aged 45–54, for every-other year from 1999 to 2013, for each of the four census regions of the United States. Death rates from these causes increased in parallel in all four regions between 1999 and 2013. Suicide rates were higher in the South (marked in black) and the West (green) than in the Midwest (red) or Northeast (blue) at the beginning of this period, but in each region, an increase in suicide mortality of 1 per 100,000 was matched by a 2 per 100,000 increase in poisoning mortality.

The focus of this paper is on changes in mortality and morbidity for those aged 45–54. However, asFig. 4 makes clear, all 5-y age groups between 30–34 and 60–64 have witnessed marked and similar increases in mortality from the sum of drug and alcohol poisoning, suicide, and chronic liver disease and cirrhosis over the period 1999–2013; the midlife group is different only in that the sum of these deaths is large enough that the common growth rate changes the direction of all-cause mortality.

Midlife Morbidity

Increases in midlife mortality are paralleled by increases in self-reported midlife morbidity. Table 2presents measures of self-assessed health status, pain, psychological distress, difficulties with activities of daily living (ADLs), and alcohol use. Each row presents the average fraction of white non-Hispanics ages 45–54 who reported a given health condition in surveys over 2011–2013, followed by the change in the fraction reporting that condition between survey years 1997−1999 and 2011−2013, together with the 95% confidence interval (CI) on the size of that change.

Table 2.

Changes in morbidity, white non-Hispanics 45–54

The first two rows of Table 2 present the fraction of respondents who reported excellent or very good health and fair or poor health. There was a large and statistically significant decline in the fraction reporting excellent or very good health (6.7%), and a corresponding increase in the fraction reporting fair or poor health (4.3%). This deterioration in self-assessed health is observed in each US state analyzed separately (results omitted for reasons of space). On average, respondents in the later period reported an additional full day in the past 30 when physical health was “not good.”

The increase in reports of poor health among those in midlife was matched by increased reports of pain. Rows 4–7 of Table 2 present the fraction reporting neck pain, facial pain, chronic joint pain, and sciatica. One in three white non-Hispanics aged 45–54 reported chronic joint pain in the 2011–2013 period; one in five reported neck pain; and one in seven reported sciatica. Reports of all four types of pain increased significantly between 1997−1999 and 2011−2013: An additional 2.6% of respondents reported sciatica or chronic joint pain, an additional 2.3% reported neck pain, and an additional 1.3% reported facial pain.

The fraction of respondents in serious psychological distress also increased significantly. Results from the Kessler six (K6) questionnaire show that the fraction of people who were scored in the range of serious mental illness rose from 3.9% to 4.8% over this period. Compared with 1997–99, respondents in 2011–2013 reported an additional day in the past month when their mental health was not good.

Table 2 also reports the fraction of people who respond that they have more than “a little difficulty” with ADLs. Over this period, there was significant midlife deterioration, on the order of 2–3 percentage points, in walking a quarter mile, climbing 10 steps, standing or sitting for 2 h, shopping, and socializing with friends. The fraction of respondents reporting difficulty in socializing, a risk factor for suicide (18, 19), increased by 2.4 percentage points. Respondents reporting that their activities are limited by physical or mental health increased by 3.2 percentage points. The fraction reporting being unable to work doubled for white non-Hispanics aged 45–54 in this 15-y period.

Increasing obesity played only a part in this deterioration of midlife self-assessed health, mental health, reported pain, and difficulties with ADLs. Respondents with body mass indices above 30 reported greater morbidity along all of these dimensions. However, deterioration in midlife morbidity occurred for both obese and nonobese respondents, and increased prevalence of obesity accounts for only a small fraction of the overall deterioration.

Risk for heavy drinking—more than one (two) drinks daily for women (men)—also increased significantly. Blood tests show increases in the fraction of participants with elevated levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) enzymes, indicators for potential inflammation of, or damage to, the liver. Nonalcoholic fatty liver disease can also elevate AST and ALT enzymes; for this reason, we show the fractions with elevated enzymes among all respondents, and separately for nonobese respondents (those with body mass index < 30).

As was true in comparisons of mortality rate changes, where midlife groups fared worse than the elderly, most of these morbidity indicators either held constant or improved among older populations over this period. With the exception of neck pain and facial pain, and enzyme test results (for which census region markers are not available), the temporal evolution of each morbidity marker presented in Table 2 is significantly associated with the temporal evolution of suicide and poisonings within census region. (Supporting Information provides details.)

Discussion

The increase in midlife morbidity and mortality among US white non-Hispanics is only partly understood. The increased availability of opioid prescriptions for pain that began in the late 1990s has been widely noted, as has the associated mortality (14, 20⇓‒22). The CDC estimates that for each prescription painkiller death in 2008, there were 10 treatment admissions for abuse, 32 emergency department visits for misuse or abuse, 130 people who were abusers or dependent, and 825 nonmedical users (23). Tighter controls on opioid prescription brought some substitution into heroin and, in this period, the US saw falling prices and rising quality of heroin, as well as availability in areas where heroin had been previously largely unknown (14, 24, 25).

The epidemic of pain which the opioids were designed to treat is real enough, although the data here cannot establish whether the increase in opioid use or the increase in pain came first. Both increased rapidly after the mid-1990s. Pain prevalence might have been even higher without the drugs, although long-term opioid use may exacerbate pain for some (26), and consensus on the effectiveness and risks of long-term opioid use has been hampered by lack of research evidence (27). Pain is also a risk factor for suicide (28). Increased alcohol abuse and suicides are likely symptoms of the same underlying epidemic (18, 19, 29), and have increased alongside it, both temporally and spatially.

Although the epidemic of pain, suicide, and drug overdoses preceded the financial crisis, ties to economic insecurity are possible. After the productivity slowdown in the early 1970s, and with widening income inequality, many of the baby-boom generation are the first to find, in midlife, that they will not be better off than were their parents. Growth in real median earnings has been slow for this group, especially those with only a high school education. However, the productivity slowdown is common to many rich countries, some of which have seen even slower growth in median earnings than the United States, yet none have had the same mortality experience (lanekenworthy.net/shared-prosperity and ref. 30). The United States has moved primarily to defined-contribution pension plans with associated stock market risk, whereas, in Europe, defined-benefit pensions are still the norm. Future financial insecurity may weigh more heavily on US workers, if they perceive stock market risk harder to manage than earnings risk, or if they have contributed inadequately to defined-contribution plans (31).

Our findings may also help us understand recent large increases in Americans on disability. The growth in Social Security Disability Insurance in this age group (32) is not quite the near-doubling shown in Table 2 for the Behavioral Risk Factor Surveillance System (BRFSS) measure of work limitation, but the scale is similar in levels and trends. This has been interpreted as a response to the generosity of payments (33), but careful work based on Social Security records shows that most of the increase can be attributed to compositional effects, with the remainder falling in the category of (hard to ascertain) increases in musculoskeletal and mental health disabilities (34); our morbidity results suggest that disability from these causes has indeed increased. Increased morbidity may also explain some of the recent otherwise puzzling decrease in labor force participation in the United States, particularly among women (35).

The mortality reversal observed in this period bears a resemblance to the mortality decline slowdown in the United States during the height of the AIDS epidemic, which took the lives of 650,000 Americans (1981 to mid-2015). A combination of behavioral change and drug therapy brought the US AIDS epidemic under control; age-adjusted deaths per 100,000 fell from 10.2 in 1990 to 2.1 in 2013 (12). However, public awareness of the enormity of the AIDS crisis was far greater than for the epidemic described here.

A serious concern is that those currently in midlife will age into Medicare in worse health than the currently elderly. This is not automatic; if the epidemic is brought under control, its survivors may have a healthy old age. However, addictions are hard to treat and pain is hard to control, so those currently in midlife may be a “lost generation” (36) whose future is less bright than those who preceded them.

Materials and Methods

Mortality Data.

We assembled data on all-cause and cause-specific mortality from the CDC Wonder Compressed and Detailed Mortality files as well as from individual death records from 1989 to 2013. For population by ethnicity and educational status, we extracted data from American Community Surveys and, before 2000, from Current Population Surveys. International data on mortality were taken from the Human Mortality Database www.mortality.org; these are not separated by race and ethnicity. Specific causes of death are constructed for 1999–2013 using International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD10) codes: alcoholic liver diseases and cirrhosis (ICD10 K70, K73-74), suicide (X60-84, Y87.0), and poisonings (X40-45, Y10-15, Y45, 47, 49). Poisonings are accidental and intent-undetermined deaths from alcohol poisoning and overdoses of prescription and illegal drugs.

Methods.

Mortality rates are presented as deaths per 100,000. These are not age-adjusted within the 10-y 45–54 age group. Information on education was missing for ∼5% of death records from 1999 to 2013 for white non-Hispanics aged 45–54. For all-cause mortality, deaths with missing education information were assigned an education category based on the distribution of education for deaths with education information, by sex and year (37). For cause-specific mortality, education was assigned based on sex, year, and cause of death.

All morbidity averages are calculated using survey-provided population sampling weights, and are presented without further statistical adjustments. We use 3 y of data to calculate averages (1997−1999 and 2011–2013), to ensure the means reported are not an aberration in any one year. Exceptions are noted.

SI Data

The NHIS and BRFSS both ask whether “health in general is excellent, very good, good, fair or poor,” and we report both positive (excellent/very good) and negative (fair/poor) responses. Table 2 reports responses to this question from the BRFSS; means from the NHIS are not statistically different from those reported. The NHIS asks questions on pain, which vary by type of pain. We score answers that a respondent had an ache or pain in a joint in the past 30 d, with symptoms first appearing more than 3 mo ago, as chronic joint pain, and answers to whether the respondent had pain in the past 3 mo lasting a whole day or more in the neck, face, or lower back pain that spread down either leg below the knee as neck pain, facial pain, and sciatica. The NHIS administers the Kessler six (K6) questionnaire, www.hcp.med.harvard.edu/ncs/k6_scales.php, scored to discriminate cases of serious psychological distress (38). We use a threshold of K6 greater than or equal to 13 as an indicator of serious psychological distress/serious mental illness. The BRFSS asks for the number of days in the past 30 mental (physical) health was “not good.” The NHIS asks about respondents’ ability to go about daily living: walking, climbing, standing, sitting, shopping, and participating in social activities. Answers on a five-point scale range from “not at all difficult” to “can’t do at all,” to which we add “do not do.” We report the fraction of people who respond that they have more than “a little difficulty” with each of these activities. The BRFSS asks respondents about current employment. Answers are coded as used for wages, out of work (less than/more than 1 y), homemaker, retired, student, or “unable to work.” We report the fraction responding that they are unable to work. The BRFSS calculates scores of heavy drinking, defined as more than one (two) drinks daily for women (men). NHANES provides results of enzyme tests, and we report the fraction with elevated enzyme readings: AST above a reference level of 48 U/L (units per liter) for men and 43 U/L for women, and ALT above a reference level of 55 U/L for men and 45 U/L for women. We use Mayo Clinic reference levels (39).

SI Materials and Methods

Calculations of deaths that would have been averted (1999−2013) use actual mortality rates observed each year compared with the rates that would have held in each year if the mortality rate had continued to fall at the speed observed for the period 1979–1998 (1.8% per year). We allow those who would have survived to face subsequent mortality risk, and we account for people aging out of the 45–54 age group. Define as the mortality rate observed for whites aged 45–54 in year t. Define as the mortality rate that would have occurred if the mortality rate had continued to fall at 1.8% per year. In 1999, lives saved are calculated using the white population aged 45–54 in 1999 ():. In 2000, lives saved are calculated based on the population that would have been observed if lives had been saved in 1999, net of those who would have died of other causes in 1999, who had not aged out of the group 45–54,

[S1]where . For year t, we construct the population from which lives would have been saved if the mortality rate had continued to fall at 1.8% per year, and calculate lives saved in year t as in Eq. S1.

The temporal associations between suicide and poisoning mortality and morbidity are established for each of our morbidity markers using least squares regressions with census region fixed effects. For census region i in year t, we ran least squares regressions of suicide and poisoning mortality combined,

With the exception of neck pain and facial pain, we find a significant association between suicide and poisoning mortality and morbidity for each morbidity marker presented in Table 2.

Acknowledgments

We thank David Cutler, Jonathan Skinner, and David Weir for helpful comments and discussions. A.C. acknowledges support from the National Institute on Aging under Grant P30 AG024361. A.D. acknowledges funding support from the National Institute on Aging through the National Bureau of Economic Research (Grants 5R01AG040629-02 and P01AG05842-14) and through Princeton’s Roybal Center for Translational Research on Aging (Grant P30 AG024928).

Footnotes

Author contributions: A.C. and A.D. designed research, performed research, analyzed data, and wrote the paper.

In the safety of her therapist’s office in late 2001, Dr. Margaret Dessau made a tape reliving what it was like to look out her living room window after she heard the boom of a hijacked plane eight blocks away.

Running naked from her bath, she saw pigeons and paper flying through the air. “It’s kind of beautiful in a way,” she recalls on the recording she made and listened to over and over as part of her treatment. “There’s these silver pieces just floating in the air.”

Her gaze met the hole in the tower. “The flames get worse, and then I start seeing all these people hanging out there. The guy with this white towel, and he’s waving it.”

He jumps. Children at a nearby school scream.

“How are you feeling?” her therapist, David Bricker, is heard asking on the tape.

One measure of the psychological impact of 9/11 is this: At least 10,000 firefighters, police officers and civilians exposed to the terrorist attack on the World Trade Center have been found to havepost-traumatic stress disorder, and in a kind of mass grieving, many of them have yet to recover, according to figures compiled by New York City’s three 9/11 health programs.

In interviews over the last several months, Dr. Dessau and others revealed a wide-ranging but consistent body of symptoms. They cannot sleep. They replay the disaster in their minds, or in theirnightmares. They have trouble concentrating. They are jittery and overreact to alarms or loud noises. They feel helpless, hopeless, guilty and cut off from the people who are close to them. They avoid anything that reminds them of that terrible day.

Millions of dollars will be spent treating them over the next few years through the James Zadroga 9/11 Health and Compensation Act, passed by Congress in December, which provides $4.3 billion to compensate and treat people with 9/11-related illnesses.

Some are emergency responders and others who vainly searched the debris for survivors. But some were residents, commuters and office workers caught in the dust cloud. And others were passive witnesses with no direct connection to the attack other than proximity.

Because of lingering questions about the bounds of the PTSD diagnosis, which is only three decades old, people with mental problems are eligible only for treatment assistance, whereas people with physical ailments, in most cases breathing difficulties, qualify for both treatment and compensation. And money available to treat patients with the stress disorder might decline if the government concludes there is a link between certain cancers and 9/11, which would give cancer patients access to the same pool of money. Doctors are expecting a surge in PTSD patients with the coming 10th anniversary, as they have on each Sept. 11.

Charles Figley, professor of disaster mental health at Tulane University’s School of Social Work and a former Marine, advanced the concept of PTSD in a 1978 book on Vietnam War veterans. He said one reason the trauma had been so hard to shake was that it ripped at the most ordinary fabric of daily life.

The landmark is not a distant hill in Afghanistan that one will never see again. “It’s the places you see every day, where you proposed to your wife, where you remember getting the news that you got promoted, where your young children played,” Dr. Figley said.

“You go into a combat zone and then you leave,” he added. “You don’t leave home. You return all the time.”

Ancient but Evolving Illness

“The Iliad” described warriors consumed by feelings of guilt, rage and grief. World War I had “shell shock,” and World War II had “combat fatigue.” PTSD has been found in survivors of Nazi concentration camps, fires and railway accidents. But it was not until 1980, after the Vietnam War, that post-traumatic stress disorder was added to the psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders.

The current manual, the DSM-IV, says PTSD can develop through a range of exposures to death or injury: direct personal involvement, witnessing it or, if it concerns someone close, just learning about it. Almost no other psychiatric diagnosis has generated as much controversy, according to Dr. Robert L. Spitzer, a retired psychiatry professor from Columbia University and an expert in mental disorder classifications. It has become so vague that stressed-out college students and people who watched horror movies could fit the profile, he and two other experts wrote in a professional journal article.

“It’s a way of saying something terrible has happened to me and I’ve been damaged in some way, but that doesn’t necessarily mean it’s an illness,” Dr. Spitzer, who advocates tightening the criteria, said in an interview.

Some experts have been skeptical of studies finding that people suffered the disorder from watching television coverage of the Sept. 11 attacks. (Congress effectively excluded TV watchers from its treatment program by requiring that victims had lived or worked within certain geographic boundaries.)

Amy Cushing-Savvi, a social worker at Mount Sinai Medical Center, which runs the largest program, said a frequent topic at staff meetings was, “What’s 9/11 and what isn’t?” — in other words, the exquisitely vexing question of how to separate the effects of 9/11 from the traumas of everyday life.

“Taxpayers could end up paying for psychotherapy for Woody Allen and half of Manhattan,” Theodore H. Frank, a fellow at the Manhattan Institute, testified before the House Judiciary Committee in April 2008, when he was a fellow at the conservative American Enterprise Institute.

Ultimately, federal financing for PTSD treatment was limited to firefighters, police officers, employees of the New York City medical examiner’s office who handled body parts, and other rescue, recovery, cleanup and support workers at ground zero, on the barges that carried debris and at the Staten Island landfill where the twin towers rubble was entombed; responders at the attack sites at the Pentagon and Shanksville, Pa.; and people exposed to 9/11 dust when the buildings collapsed or who lived, worked or attended school south of Houston Street in Manhattan and in parts of Downtown Brooklyn where the dust may have extended.

Family members of New York City firefighters who died are covered as a continuation of an existing Fire Department counseling program, but family members of other victims are not. Representative Carolyn B. Maloney, Democrat of New York and the lead sponsor of the Zadroga Act in the House, said that since victims’ families had been covered by the original 9/11 compensation fund, which paid an average of $2.1 million to each family, the goal was to look after others who suffered. “We were focusing on covering the people who did not die on 9/11, but those who were dying and sick because of 9/11,” she said.

The law was named after a New York police detective who took part in the rescue efforts and later developed breathing complications. The cause of his death in 2006 became a source of debate.

Dr. John Howard, who oversees 9/11 programs as the director of the National Institute for Occupational Safety and Health, said in an interview that he was willing to give people the benefit of the doubt about PTSD, even if they had other stresses. “Collapsing 220 stories of a lot of material in one of the most densely populated cities in the world is a very unique event,” Dr. Howard said.

“In mental health you have to treat the whole person, and you can’t really separate out some of these other influences, personal stressors, economic issues. People are living their lives.”

“It sounds squishy,” he added, “but it really isn’t squishy.”

Her World Collapses

For Dr. Dessau, who is now 64, listening to the tapes she made during therapy conquered her fears for a while, “like cod liver oil,” she said. But in 2009, her sense of tragedy was compounded when her husband, Bob Wheeler, died just four months after being told he had lung cancer.

Dr. Dessau, a youthful, athletic blonde with blue-rimmed green eyes, still lives in the same airy loft on Greenwich Street, decorated with souvenirs of 35 years of travel with Mr. Wheeler — shells arranged in bowls, a child-size winged Hermes, a many-limb stone goddess, a terra cotta Chinese statue of a man. There is also a green plastic box containing her husband’s ashes.

Mr. Wheeler, a lawyer, never smoked, so Dr. Dessau, a pulmonologist, suspected that his disease was related to his exposure to the falling buildings. His quick death revived the sense of helplessness she had felt watching people jump from the towers. “As a doctor you always think you can fix it,” she said.

She lost 20 pounds. She stopped seeing friends. She was “on red alert,” sure that something bad would happen at any second. She avoids looking at the skyline outside her window, though her reaction is not as bad since buildings have begun to fill in the space where the World Trade Center used to be.

A city fund set up before the Zadroga Act was enacted provided $9,000 to Dr. Dessau to cover therapy expenses not handled by her insurance. The city sent a letter encouraging her to seek further treatment through a public program that would allow the Zadroga money to cover her out-of-pocket expenses, but she prefers her own therapist.

She sees 9/11 and her husband’s death as part of a continuum, along with her parents’ escape from Nazi Germany, the suicide of a close relative and her time preparing bandages as a student in Israel during the 1967 Arab-Israeli war. “It confirms my sense of pessimism,” she said. “It’s corroboration of the evil of human beings.”

That sense of 9/11 as a catalyst is common. In June, Stanley Mieses, 58, a freelance writer and editor, lined up with other psychiatric patients at the city-run Elmhurst Hospital Center under a sign that said, as if testing his sanity: New atient Registrati n.

During a screening, he circled the maximum, “nearly every day,” to a question about how often he had been “feeling bad about yourself — or that you are a failure or have let yourself or your family down.”

Mr. Mieses, who is receiving treatment under the Zadroga Act, lived six and a half blocks from the trade center and watched the buildings collapse. The police evacuated him, but he returned every few days to feed his cats. “Dead people were blowing into my apartment off the windowsills,” he said, remembering the ash, “because the landlord was too cheap to clean it.”

For a while he sublimated his anxiety, filing reports for NPR from his stunned neighborhood. But in short order, his mother, a World War II German refugee with what he said were her own PTSD issues, died; his girlfriend left him; work dried up; and he was forced by his finances to move to Jackson Heights, Queens.

These psychic blows led, he said, to “a change in my attitude, a change in my — I don’t know — joie de vivre.”

His pulmonologist at Elmhurst says his shortness of breath could be from the dust, or the 20 years he smoked. The origins of his mental wounds are also ambiguous. “I tend to think of 9/11 as the trapdoor that opened up,” Mr. Mieses said. “Whatever else I’m doing past that, is climbing back up.”

A Number Unknown

It is impossible to say how many people have 9/11-related PTSD. The city’s three official programs do not count people, like Dr. Dessau, who use private physicians — or those who have not been treated at all.

According to figures provided by the programs, run by the Fire Department, which treats its own employees; a consortium of hospitals led by Mount Sinai Medical Center, which treats police officers and other rescue and recovery workers; and the city’s public hospital system, which treats civilians, at least 10,000 patients have met the criteria over the last decade, and at least 3,600 of them still have symptoms. But even those rounded numbers have an asterisk: 3,000 of the 10,000 patients were treated by the public hospitals, whose statistics do not differentiate among PTSD, depression and anxiety. The Zadroga program covers all three, along with panic disorder, substance abuse and a few other conditions.

Extrapolating from a registry of people exposed to the attack, the city’s health department has estimated that 61,000 of the 409,000 in the disaster area experienced “probable” PTSD within six years of 9/11. But these numbers were produced by institutions and a city government with two main goals: to make as many people as possible feel better, and to try to persuade Congress to provide a steady stream of treatment money. The city’s 9/11 health programs have created a huge intake system that screens every patient for mental as well as physical illness, and the public hospitals reached out to New Yorkers with subway advertisements that said: “Lived there? Worked there? You deserve care.”

No one can say exactly how many people were exposed to the attack, and how many will eventually become physically or mentally sick. The federal government will allow the Mount Sinai and public hospitals programs to grow by 25,000 patients each over the next five years. It will be up to each program to decide who qualifies for treatment, but they will have to use uniform criteria approved by the government. Therapy can cost $135 for a 45-minute weekly session with a psychologist or $165 with a psychiatrist.

If the government finds a link between 9/11 dust and cancer, there is some concern about running out of money, though the Zadroga fund is to be a secondary payment source, covering what insurance and workers’ compensation do not.

Dr. Howard, the federal 9/11 health administrator, said the government “will treat people as they come in to the extent possible.”

Alarms, Over and Over

Patients at Mount Sinai find a busy warren of rooms where they are divided into three categories: green (no further assessment needed), yellow (potentially symptomatic) and red (symptoms so severe that they might be suicidal). They begin the screening at home, filling out an 11-page questionnaire that asks about their level of energy, how often they feel “calm and peaceful,” and about recent life experiences like losing a job or having a relationship break up. In a section called “Reminders of 9/11,” they are asked whether they have recurring thoughts of the disaster and whether they feel emotionally cut off from those close to them.

In an interview with a clinician, they are asked whether “you often believe it would be better if you were dead,” “you feel worthless” or “you feel guilty even though you didn’t deserve to feel that way.”

If they have PTSD, patients are usually given a combination of psychotherapy and pills, typicallyantidepressants, and sometimes sleeping pills. Many patients are encouraged to make recordings of their memories, as Dr. Dessau did, or to write about them until the memories lose their power. This is called exposure therapy.

Once a month, Earl Holland drives from his home in Flatlands, Brooklyn, to Mount Sinai for meditation classes. “You get in a room, the chimes are going, it’s fantastic,” Mr. Holland said. He also takes Wellbutrin, an antidepressant, and Ambien, a sleeping pill.

Mr. Holland, 48, was a paramedic supervisor for North Shore-Long Island Jewish Health System when he responded to the disaster after the second tower collapsed. In his dreams, he still hears the alarms — attached to each firefighter’s mask — that signal that a firefighter has stopped moving. “There were hundreds of alarms going off,” he said, grabbing a tissue to wipe away the tears as he sat in his kitchen, remembering.

“I kept the list” of the missing, he said.

Two months after the attacks, he responded to the crash of American Airlines Flight 587 in Belle Harbor, Queens.

He started shutting himself in his bedroom, refusing to talk to his wife and children. He spent hours staring at photographs of the burning rubble and had flashbacks of responding to murders during the 1980s crack epidemic.

“Toward the end, I didn’t want to do my calls,” he said. “It was like, enough. I actually thought it was burnout, but it wasn’t burnout.”

Mr. Holland’s diagnosis of PTSD was made in 2009 through a Mount Sinai outreach program, and his costs will be covered by the Zadroga Act.

He has recovered enough that he hopes to return to work, but not on the front lines. “I don’t know if I’ll go to the memorial any time soon,” he said. “I look at that kind of as closure, if I’m able to do that.”

On this 11th anniversary of the terrorist attacks on the U.S. in New York City and Washington, DC, we are reminded not only of the sacrifice of the hundreds of first-responders — firemen, police, and emergency medical personnel — but also of the long-term impact of the tragedy on those who survived.

Those who survived didn’t do so in a vacuum; they had to relive the tragedy on the news day in and day out for weeks thereafter.

As the weeks turned into months turned into years, some of the effects of 9/11 could be felt long after the initial destruction. They weren’t always physical effects either — many people suffered from mental health problems such as post-traumatic stress disorder (PTSD) for years after.

About a year ago, a research study examined some of these effects. Here’s what they found.

The study was conducted by Perlman et al. and looked at all of the health and psychology research literature in PubMed related to the 9/11 attacks. The researchers found more than 150 studies looking at the mental health effects alone.

While the attacks occurred in two specific geographical areas in the U.S., the entire U.S. population felt the impact of the attacks:

Measurements taken 3–5 days after 9/11 suggested that 44% of the adult US population experienced substantial stress. Findings from subsequent national studies also showed that individuals across the country experienced fear and insecurity, and had increased rates of post-traumatic stress (PTSD) symptoms 2 months later.

Most people who lived and worked in New York City around the World Trade Center felt the impact of the attacks. But those who immediately responded to the tragedy bore the highest burden:

[The] prevalence of PTSD 2-3 years after 9/11 was 12.4% in rescue and recovery workers and volunteers, with a range from 6.2% for police to 21.2% for unaffiliated volunteers.

The children of New York City were also impacted:

The severity of children’s reactions has been positively correlated with parental distress (parental post-traumatic stress and crying in front of the child) and with the number of graphic images seen on television.

This could argue for parents working to limit their children’s access to graphic images of a future tragedy. Although in today’s age of mobile connectivity, such limits may be practically impossible to enforce.

The mental health effects of 9/11 can be felt long after the attacks… and even intensify over the years:

In people […] who did not report a PTSD diagnosis before 9/11, the prevalence
of the disorder was higher 5-6 years after the attacks (19%) than after 2-3 years (14%). Late-onset PTSD (a report of symptoms consistent with PTSD in the 2006-07 survey, but not in the 2003–04 survey) had developed in 10%.

And of course, in the real world, disorders rarely occur by themselves. A diagnosis of PTSD often brings additional diagnoses along with it:

In enrollees in the WTC Health Registry who screened positive for chronic PTSD symptoms after the disaster, a third also reported a diagnosis of depression since 9/11.

Responders with probable PTSD had 13.9 times higher odds for probable depression and 9.2 times higher odds of panic disorder than those without PTSD; comorbid responders were 40–86 times more likely to have emotional disruption of function […] than were those without PTSD, panic disorder, or depression.

All of this speaks to the impact such a human tragedy can have on the people who live through it, experience it through the media, and have to remember it on days like today.

Our hearts go out to all of those who lost family members in the attacks, and those who are still re-living the events of that day like they occurred yesterday.

The Foundations of Geopolitics, initially published in 1997 when Vladimir Putin became FSB chief, is a military training textbook which has influenced key Russian decision-makers. It states that Russia should use its special forces within the borders of the United States to:[2]

introduce geopolitical disorder into internal American activity, encouraging all kinds of separatism and ethnic, social and racial conflicts, actively supporting all dissident movements – extremist, racist, and sectarian groups, thus destabilizing internal political processes in the U.S. It would also make sense simultaneously to support isolationist tendencies in American politics.

A report by the U.S. Census Bureau projects a decrease in the ratio of Whites between 2010 and 2050, from 79.5% to 74.0%.[60] At the same time,Non-Hispanic Whites are projected to no longer make up a majority of the population by 2042, but will remain the largest single ethnic group. In 2050 they will compose 46.3% of the population. Non-Hispanic whites made up 85% of the population in 1960.[61]

The report foresees the Hispanic or Latino population rising from 16% today to 30% by 2050, the Black percentage barely rising from 12.9% to 13.1%, and Asian Americans upping their 4.6% share to 7.8%. The United States had a population of 310 million people in October 2010, and is projected to reach 400 million by 2039 and 439 million in 2050.[20][62][63][64] It is further projected that 82% of the increase in population from 2005 to 2050 will be due to immigrants and their children.[65]

Of the nation's children in 2050, 62% are expected to be of a minority ethnicity, up from 44% today. Approximately 39% are projected to be Hispanic or Latino (up from 22% in 2008), and 38% are projected to be single-race, non-Hispanic Whites (down from 56% in 2008).[66]

After more than four decades of serving as the nation’s economic majority, the American middle class is now matched in number by those in the economic tiers above and below it. In early 2015, 120.8 million adults were in middle-income households, compared with 121.3 million in lower- and upper-income households combined, a demographic shift that could signal a tipping point, according to a new Pew Research Center analysis of government data.

In at least one sense, the shift represents economic progress: While the share of U.S. adults living in both upper- and lower-income households rose alongside the declining share in the middle from 1971 to 2015, the share in the upper-income tier grew more.

Over the same period, however, the nation’s aggregate household income has substantially shifted from middle-income to upper-income households, driven by the growing size of the upper-income tier and more rapid gains in income at the top. The share accruing to middle-income households was 43% in 2014, down substantially from 62% in 1970.

And middle-income Americans have fallen further behind financially in the new century. In 2014, the median income of these households was 4% less than in 2000. Moreover, because of the housing market crisis and the Great Recession of 2007-09, their median wealth (assets minus debts) fell by 28% from 2001 to 2013.

Meanwhile, the far edges of the income spectrum have shown the most growth. In 2015, 20% of American adults were in the lowest-income tier, up from 16% in 1971. On the opposite side, 9% are in the highest-income tier, more than double the 4% share in 1971. At the same time, the shares of adults in the lower-middle or upper-middle income tiers were nearly unchanged.

These findings emerge from a new Pew Research Center analysis of data from the U.S. Census Bureau and the Federal Reserve Board of Governors. In this study, which examines the changing size, demographic composition and economic fortunes of the American middle class, “middle-income” Americans are defined as adults whose annual household income is two-thirds to double the national median, about $42,000 to $126,000 annually in 2014 dollars for a household of three. Under this definition,

Are you in the American middle class?

Our new calculator allows you to see which group you fit in, first compared with all American adults, and then compared with other adults similar to you in education, age, race or ethnicity, and marital status.

The state of the American middle class is at the heart of the economic platforms of many presidential candidates ahead of the 2016 election. Policymakers are engaged in debates about the need to raise the floor on wages and on how best to curb rising income inequality. Meanwhile, President Barack Obama uses the term “middle-class economics” to describe his economic agenda. And a flurry of new research points to the potential of a larger middle class to provide the economic boost sought by many advanced economies.

The news regarding the American middle class is not all bad. Although the middle class has not kept pace with upper-income households, its median income, adjusted for household size, has risen over the long haul, increasing 34% since 1970. That is not as strong as the 47% increase in income for upper-income households, though it is greater than the 28% increase among lower-income households.

Moreover, some demographic groups have fared better than others in moving up the income tiers, while some groups have slipped down the ladder. The groups making notable progress include older Americans, married couples and blacks. Despite this progress, older Americans and blacks remain more likely to be lower income and less likely to be upper income than adults overall. Those Americans without a college degree stand out as experiencing a substantial loss in economic status.

In addition to changes in the size and economic standing of the American middle class, its demographic profile has changed significantly in recent decades. Some of the changes reflect long-term demographic trends in the U.S., as the middle class is in many ways a mirror of the broader population. For example, the aging of the country, the growing racial and ethnic diversity, the decline in marriage rates and the overall rise in educational attainment are all reflected in the changing composition of the middle class.

Who is middle income?

In this report, “middle-income” households are defined as those with an income that is 67% to 200% (two-thirds to double) of the overall median household income, after incomes have been adjusted for household size. Lower-income households have incomes less than 67% of the median, and upper-income households have incomes that are more than double the median.

The income it takes to be middle income varies by household size, with smaller households requiring less to support the same lifestyle as larger households. For a three-person household, the middle-income range was about $42,000 to $126,000 annually in 2014. However, a one-person household needed only about $24,000 to $73,000 to be middle income. For a five-person household to be considered middle income, its 2014 income had to range from $54,000 to $162,000.

In addition, the lower-income group is divided into lowest-income households (with income less than half of the overall median) and lower-middle income households (with incomes from half to less than two-thirds of the overall median). In 2014, a lowest-income household with three people lived on about $31,000 or less, and a lower-middle income household lived on about $31,000 to $42,000.

Likewise, upper-income households are divided into upper-middle income households (with more than twice the overall median income and up to three times the median) and highest-income households (with more than three times the overall median income). In 2014, an upper-middle income household with three people lived on about $126,000 to $188,000, and a highest-income household lived on more than $188,000.

Middle income or middle class?

The terms “middle income” and “middle class” are often used interchangeably. This is especially true among economists who typically define the middle class in terms of income or consumption. But being middle class can connote more than income, be it a college education, white-collar work, economic security, owning a home, or having certain social and political values. Class could also be a state of mind, that is, it could be a matter of self-identification (Pew Research Center, 2008, 2012). The interplay among these many factors is examined in studies by Hout (2007) and Savage et al. (2013), among others.

This report uses household income to group people. For that reason, the term “middle income” is used more often than not. However, “middle class” is also used at times for the sake of exposition.

The middle class shrinks

The hollowing of the American middle class has proceeded steadily for more than four decades. Since 1971, each decade has ended with a smaller share of adults living in middle-income households than at the beginning of the decade, and no single decade stands out as having triggered or hastened the decline in the middle.

Based on the definition used in this report, the share of American adults living in middle-income households has fallen from 61% in 1971 to 50% in 2015. The share living in the upper-income tier rose from 14% to 21% over the same period. Meanwhile, the share in the lower-income tier increased from 25% to 29%. Notably, the 7 percentage point increase in the share at the top is nearly double the 4 percentage point increase at the bottom.

The rising share of adults in the lower- and upper-income tiers is at the farthest points of the income distribution, distant from the vicinity of the middle. The share of American adults in the lowest-income tier rose from 16% in 1971 to 20% in 2015. Over the same period, the share of American adults in lower-middle income households did not change, holding at 9%.

The growth at the top is similarly skewed. The share of adults in highest-income households more than doubled, from 4% in 1971 to 9% in 2015. But the increase in the share in upper-middle income households was modest, rising from 10% to 12%. Thus, the closer look at the shift out of the middle reveals that a deeper polarization is underway in the American economy.

The gaps in income and wealth between middle- and upper-income households widened substantially in the past three to four decades. As noted, one result is that the share of U.S. aggregate household income held by upper-income households climbed sharply, from 29% in 1970 to 49% in 2014. More recently, upper-income families, which had three times as much wealth as middle-income families in 1983, more than doubled the wealth gap; by 2013, they had seven times as much wealth as middle-income families.

Trends in income

Households in all income tiers experienced gains in income from 1970 to 2014. But the gains for middle- and lower-income households lagged behind the gains for upper-income households.

The median income of upper-income households increased from $118,617 in 1970 to $174,625 in 2014, or by 47%. That was significantly greater than the 34% gain for middle-income households, whose median income rose from $54,682 to $73,392. Lower-income households fell behind even more as their median income increased by only 28% over this period.

Although 2014 incomes are generally higher than in 1970, all households experienced a lengthy period of decline in the 21st century thanks to the 2001 recession and the Great Recession of 2007-09. The greatest loss was felt by lower-income households, whose median income fell 9% from 2000 to 2014, followed by a 4% loss for middle-income households and a 3% loss for upper-income households.

Trends in wealth

The Great Recession of 2007-09, which caused the latest downturn in incomes, had an even greater impact on the wealth (assets minus debts) of families. The losses were so large that only upper-income families realized notable gains in wealth over the span of 30 years from 1983 to 2013 (the period for which data on wealth are available).

Before the onset of the Great Recession, the median wealth of middle-income families increased from $95,879 in 1983 to $161,050 in 2007, a gain of 68%. But the economic downturn eliminated that gain almost entirely. By 2010, the median wealth of middle-income families had fallen to about $98,000, where it still stood in 2013.

Upper-income families more than doubled their wealth from 1983 to 2007 as it climbed from $323,402 to $729,980. Despite losses during the recession, these families recovered somewhat since 2010 and had a median wealth of $650,074 in 2013, about double their wealth in 1983.

The disparate trends in the wealth of middle-income and upper-income families are due to the fact that housing assumes a greater role in the portfolios of middle-income families. The crash in the housing market that preceded the Great Recession was more severe and of longer duration than the turmoil in the stock market. Thus, the portfolios of upper-income families performed better than the portfolios of middle-income families from 2007 to 2013. When all is said and done, upper-income families, which had three times as much wealth as middle-income families in 1983, had seven times as much in 2013.

Demographic winners and losers

As the middle has hollowed, some demographic groups have been more likely to advance up the income tiers (winners) while others were more likely to retreat down the economic ladder (losers).

Nationally, the share of adults in the upper-income tier increased from 14% in 1971 to 21% in 2015, a gain of 7 percentage points. Meanwhile, the share of adults in the lower-income tier also rose, from 25% to 29%, an increase of 4 percentage points. The difference – 3 percentage points – is the netgain for American adults. By the same measure, the net gain in economic status varied across demographic groups.

The biggest winners since 1971 are people 65 and older. Not coincidentally, the poverty rate among people 65 and older fell from 24.6% in 1970 to 10% in 2014. Evidence shows that rising Social Security benefits have played a key role in improving the economic status of older adults. The youngest adults, ages 18 to 29, are among the notable losers with a significant rise in their share in the lower-income tiers.

The economic status of adults with a bachelor’s degree changed little from 1971 to 2015, meaning that similar shares of these adults were lower-, middle- or upper-income in those two years. Those without a bachelor’s degree tumbled down the income tiers, however. Among the various demographic groups examined, adults with no more than a high school diploma lost the most ground economically.

Winners also include married adults, especially couples where both work. On the flip side, being unmarried is associated with an economic loss. This coincides with a period in which marriage overall is on the decline but is increasingly linked to higher educational attainment.

Gains for women edged out gains for men, a reflection of their streaming into the labor force in greater numbers in the past four decades, their educational attainment rising faster than among men, and the narrowing of the gender wage gap.

Among racial and ethnic groups, blacks and whites came out winners, but Hispanics slipped down the ladder. Although blacks advanced in income status, they are still more likely to be lower income and less likely to be upper income than whites or adults overall. For Hispanics, the overall loss in income status reflects the rising share of lower-earning immigrants in the adult population, from 29% in 1970 to 49% in 2015. Considered separately, both U.S.-born and foreign-born Hispanics edged up the economic tiers.

Road map to the report

This report divides households into three income tiers – lower income, middle income and upper income – depending on how their income compares with overall median household income. The analysis focuses on changes in the size and demographic composition of the three income tiers and on trends in their economic wellbeing. Unless otherwise noted, incomes are adjusted for household size and scaled to reflect a household size of three.

Households that are in the lower-, middle- or upper-income tier in one year are compared with households that are in one of those tiers in another year. The analysis does not follow the same households over time, and some households that were middle income in one year, say, may have moved to a different tier in a later year. The demographic composition of each income tier may also have changed from one year to the next.

The next section of the report describes the size of the U.S. adult population in each income tier and analyzes how it changed from 1971 to 2015. The lower- and upper-income tiers are also subdivided into two tiers each for a closer examination of the dispersion of the adult population: lowest income, lower-middle income, upper-middle income and highest income.

The report then turns to a demographic analysis of the three main income tiers. First, the report examines how changes in the size of lower-, middle- and upper-income tiers have played out differently across demographic groups. The key demographic breaks include age, marital status, gender, race and ethnicity, nativity, education, occupation and industry. Next, the report briefly examines the demographic composition of the middle-income population and how it compares with the population of adults overall and adults in lower- and upper-income tiers.

The final two sections of the report focus on the economic wellbeing of middle-income households, including how it has changed over time and how it compares with the wellbeing of lower- and upper-income households. The first of these two sections examines trends in household income and the second focuses on family wealth, assets and debts.

“Middle-income” households are defined as those with an income that is two-thirds to double that of the U.S. median household income, after incomes have been adjusted for household size. For a three-person household, the middle-income range was about $42,000 to $126,000 annually in 2014 (in 2014 dollars). Lower-income households have incomes less than two-thirds of the median, and upper-income households have incomes that are more than double the median.

Unless otherwise noted, incomes are adjusted for household size and scaled to reflect a household size of three. Adults are placed into income tiers based on their household income in the calendar year previous to the survey year. Thus, the income data in the report refer to the 1970-2014 period, and the demographic data from the same survey refer to the 1971-2015 period.

Whites, blacks and Asians include only the single-race, non-Hispanic component of those groups. Hispanics are of any race. Asians include Pacific Islanders. Other racial/ethnic groups are included in all totals but are not shown separately.

Adults with a high school education are those who have obtained a high school diploma or its equivalent, such as a General Educational Development (GED) certificate. Adults with “some college” education comprise those completing associate degrees as well as those completing any college at all, including less than one year. Prior to 1990, adults “with at least a college degree” refer to those who completed at least four years of college.

“Unmarried” includes “married, spouse absent,” never married, divorced, separated and widowed. “Married” includes opposite-sex couples only, because trends are not available for same-sex couples. “With children at home” includes adults with at least one biological, adopted or step child of any age in the household.

“Foreign born” refers to people born outside of the United States, Puerto Rico or other U.S. territories to parents neither of whom was a U.S. citizen, regardless of legal status. The terms “foreign born” and “immigrant” are used interchangeably in this report.

“U.S. born” refers to individuals who are U.S. citizens at birth, including people born in the United States, Puerto Rico or other U.S. territories, as well as those born elsewhere to parents who were U.S. citizens.

To understand the state of the Democratic presidential race, look no further than an exchange midway through Saturday night’s debate about American policy in Syria.

The differences between Hillary Clinton, Bernie Sanders, and Martin O’Malley are fairly simple. Clinton wants to create a no-fly zone in Syria, and she believes that it’s important to keep working to remove President Bashar al-Assad from power. Sanders thinks the focus on regime change is misguided, and contends that Middle Eastern countries ought to be leading the fight against ISIS on the ground. O’Malley, too, is wary of regime change and foreign involvement. But as the conversation progressed, Clinton simply ran circles around her opponents, offering far more detail and demonstrating how much more she knows about foreign policy—both in general and in the specific case of Syria.

Thus the major dilemma for Democratic voters in 2016: Do they support Sanders, a guy whose positions are in line with the party’s mainstream, but who obviously has a fairly superficial, ideologically rigid engagement with foreign policy? Or do they support Clinton, who has a more powerful, detailed, and nuanced command of the issues than any other candidate, but is also far more hawkish than most Democrats?

So far, a majority of them have chosen to support Clinton—though Sanders leads in New Hampshire, where the debate was held. (O’Malley is in the low single digits both nationwide and in the Granite State.) But issue after issue in Saturday’s debate revealed the same dynamic. Clinton simply offers a far more commanding presence—able to dive into the details of almost any policy at a moment’s notice. Yet in many cases, it’s Sanders’s dour, more Manichean views that resonate more with many Democratic primary voters like, his desire to aggressively combat income inequality, provide better benefits, and clamp down on big banks. In several places, the contrast between the two couldn’t have been more clear, as when Sanders demanded to know why the U.S. doesn’t guarantee health care as a basic right, or when Clinton pledged not to raise taxes on the “middle class”—defining it as every household earning less than an astronomical $250,000.

One reason Clinton retains a commanding lead is that—despite what you may have heard after the 2008 election—she’s a pretty talented politician. Clinton is ready with a smile, a quip, a raised eyebrow, or whatever the moment calls for. On several occasions, Clinton was left smiling with equanimity as her two rivals heatedly shouted on either side of her. It positions her well.

Headed into the debate, there was an expectation (leavened with much dread) that there would be extensive conversation about the Sanders campaign accessing Clinton campaign information from a shared database, and the Sanders campaign’s subsequent brawl with the Democratic National Committee. Instead, blessedly, the matter was dismissed quickly. The first question of the night went to Sanders about the breach, and he apologized both to Clinton and to his supporters. She accepted just as quickly, adding: "Now that we’ve resolved your data, we’ve agreed on an independent inquiry, we should move on. I don’t think the American people are all that interested in this." In that way, she closely echoed Sanders’s own comments in the first debate, when he dismissed questions about heremails. One good turn on a cyber-security scandal, it seems, deserved another.

There was much more extensive discussion about domestic terrorism. Democratic candidates are in a bind: There’s only so much they can do to distance themselves from the Obama administration, and anyway, they don’t believe the hardline policies that Republicans are pushing would work. Yet they also have to show that they’re concerned and have a plan to soothe an anxious electorate. Bernie Sanders gave perhaps the most interesting answer of the night, responding to Donald Trump’s call to bar Muslim immigrants. Trump’s decision to exploit anxiety about terrorism is all a big diversion, Sanders said, designed to distract from anxieties about the economy. In short, Sanders was invoking the old Marxist idea of false consciousness. It’s easy to mock as a classic Sanders move, pivoting as quickly as possible from security to the economy. But it’s an insightful analysis of Trump’s campaign, in which a billionaire elitist has managed to marshal the support of working-class voters behind an ultimately vague and shifting platform papered over with xenophobic fear-mongering.

Martin O’Malley needed a turning point; his campaign is running low on followers and cash. It’s hard to believe the debate provided him with such a moment. The former Maryland governor delivered a feisty performance, jumping in to try to make himself relevant. In some cases, that ought to be have been relatively easy; he was, for instance, calling for compassion for refugees long before his rivals. But O’Malley often came across mostly as shouty and angry. His attempt to spotlight his youth—“May I offer a different generation's perspective on this?"—drew boos from the hall. (Besides, he’s older than Marco Rubio and Ted Cruz.) Yet when O’Malley attacked Sanders and Clinton over their records on gun control, they effectively pushed him aside like a small child. "Let's tell the truth here, Martin," Clinton said. "Let's calm down a little bit,” Sanders said. When the proudly cranky Sanders tells you it’s time to calm down ...

Clinton’s weaknesses as a candidate haven’t gone away. She offered several shaky answers Saturday night. She got tripped up by a question over whether the Affordable Care Act was working and how she’d improve it. Her answers about how she’d stop domestic terror were vague at best. Defining the middle class as those making up to $250,000 seems out of touch with the leftward-shifting Democratic Party. But this debate seems likely to just reinforce the status quo, which means it was a good night for Hillary Clinton.

Failing that, the debate took place on the Saturday night before Christmas, so who will notice anyway?

—David Graham

10:55 pm: Say what you will about Hillary's tendency to pander, which is totally egregious, she does have a sense for what people want to hear. —Molly Ball

10:52 pm: Clinton: "Thank you, good night, and may the force be with you” —Molly Ball

10:51 pm: Clinton: If the next president is a Republican, women's rights, voters’ rights, gay rights, and workers’ rights will be at risk; also social security, the VA, and Planned Parenthood. "The differences are so stark. This is a watershed election," she says. In the wake of Sanders vs. DNC, she touts the need for "a Democrat" in the White House. "I want to make sure every child has a chance." —Molly Ball

10:50 pm: In addressing women's rights, voter rights, Planned Parenthood, and other issues, Clinton's closing remarks aren't focused on what sets her apart as a candidate. They're about what she thinks separates the Democratic Party from the Republican Party.— Nora Kelly

10:49 pm: O'Malley: "Here in New Hampshire, the individual matters." This has been a healthy exchange of ideas about making people's lives better. He also goes after the Republicans for stoking anger and fear. He touts comprehensive immigration reform, infrastructure investment, and addressing climate change. "Join this campaign for the future," he says. —Molly Ball

10:46 pm: Sanders seeks an optimistic note: We can all agree the Republicans are wrong; I am a human whose parents had dreams. "I know something about economic anxiety," he says, throwing in a reference as well to "political revolution." —Molly Ball

10:57 pm: Thanks to KFI's radio broadcast, I managed to catch the candidates' exchange on Syria while in transit between holiday parties, and was struck by the similarities with the Republican field. In both primaries there is a "Washington establishment consensus" faction (Marco Rubio, Jeb Bush, Hillary Clinton) that believes the United States ought to fight ISIS and seek regime change in Syria simultaneously, even though it means conflict with Russia. And there is a dissident, "outsider" faction (Donald Trump, Ted Cruz, Bernie Sanders) that believes the U.S. should forget regime change and focus on destroying ISIS in cooperation with Russia. It may seem strange that Bernie Sanders and Donald Trump/Ted Cruz have more in common with one another on a defining issue than they do with fellow partisans, but on foreign policy, the Washington establishment is both powerful and incompetent enough that more and more Americans are ready to depose it. —Conor Friedersdorf

10:40 pm: In another awkward interlude, ABC’s anchors point out that Donald Trump isn’t live tweeting tonight’s debate. They sound wistful; it makes me wonder if part of the plan for these interludes was to let them read Trump tweets aloud. But whoever’s staffing Hillary’s account is doing a superb job of live tweeting:

—Yoni Appelbaum

10:38 pm: The moderators clearly wanted to ask Hillary what Bill Clinton's role in her administration would be, but they did it really clumsily. To defuse criticism they're now putting the spouse question to the male candidates, too—and it's the least interesting thing ever. —Molly Ball

10:38 pm: “We’ll be back for much more from New Hampshire,” David Muir threatens the hundreds still watching. —Yoni Appelbaum

10:35 pm: Sanders gets a version of the same question, in a ham-handed effort at equity. He uses it to praise Hillary’s redefinition of the role of First Lady, and to deliver a touching tribute to his own wife. —Yoni Appelbaum

10:35 pm: But as far as picking the flowers and china for state dinners, that’ll probably still fall to Hillary, she says. —Priscilla Alvarez

10:35 pm: Clinton, who's answered a million questions on this topic, seems flustered, just taken aback by what a bizarre question it is. —David Graham

10:33 pm: We're wrapping things up here, per Raddatz. And taking a "very sharp turn" away from foreign policy in Libya to the role of a president's spouse.—Nora Kelly

10:29 pm: This bugs me. Bill Clinton pioneered the, "Here's a random person I met and learned from” approach, but no one pulls it off like he does; instead it often comes off as "I am a robot stiffly trying to relate to humanity.” —Molly Ball

10:28 pm: That's a good observation, Priscilla. But as The Washington Post's Alexandra Petri jokes on Twitter, it frames the people he's met (and in the case of his family, loved) as mere anecdotes. He might want to tone down the personalization:

10:27 pm: O’Malley talks about a friend who struggled with addiction when fielding the question on drugs. It’s been a regular strategy of O’Malley’s during this debate to personalize his responses and invoke relationships he’s had that are relevant to the issue. —Priscilla Alvarez

10:25 pm: Clinton's people point to the heroin epidemic as an example of the effectiveness of her "listening tour" approach over the summer, which some critiqued as sheltering her from the campaign for too long—but which put the issue on her radar. It's a testament to the power of the early states to elevate local issues—even the Republican candidates are talking about the opiate epidemic—and makes one wonder what issues are happening in other states, out of view of the candidates. —Molly Ball

10:23 pm: The question on the heroin crisis underlines something we’ve reported before—that heroin is being treated as a public-health crisis, and not a criminal-justice crisis. It’s hard not to wonder if the demographics of heroin addicts don’t play a large role in that; it’s not just an inner-city problem, it affects even heavily rural, white states like New Hampshire and Vermont. —Yoni Appelbaum

10:22 pm: This is the first time that I recall drugs coming up during a debate. In this case, heroin as a result of the crisis occurring in New Hampshire. —Priscilla Alvarez

10:22 pm: Sanders addresses community-police tensions with a pro-diversity message, and a dash of his economic policy:"We need to make police departments look like the communities they serve. ... We need basically to pledge that we're going to invest in jobs and education, not jails and incarceration." —Nora Kelly

10:18 pm: Not wholly convinced that Martin O’Malley’s effort to hold up Baltimore as a national model for effective, honest policing is going to win over many listeners. —Yoni Appelbaum

10:17 pm: Sanders emphasized his support of paid family leave in that tax exchange—an echo of his lobbying last month for Clinton to support a Senate paid family leave bill. It left Clinton trying to break through the crowd applause to say she supports it, too. —Nora Kelly

10:09 pm: In many ways, the last exchange was the most illuminating on domestic issues. Hillary’s defense of the middle-class is built around a pledge not to raise taxes on those earning $250,000 or less. That’s both a fairly elastic definition of “middle class,” and one which assumes that the best way to help them is not to tax them. But Sanders offers a strikingly different approach, arguing—in essence—that taxes can be used to pay for things that are worth a great deal more than they cost. That’s a fairly fundamental difference, and explains their contrasting positions on a host of issues. —Yoni Appelbaum

10:06 pm: Bernie invokes FDR’s Social Security, LBJ’s Medicare, and current proposals for paid family and medical leave to make the point that modest tax increases, including those that hit the middle class, are sometimes worth it. —Yoni Appelbaum

10:04 pm: Bernie on the upcoming tax questions: “Now this is getting to be fun." —Priscilla Alvarez

10:03 pm: Hillary condescendingly praises Sanders’s “commitment to really changing the systems—free college, single-payer healthcare” but then slams him on the cost, which she puts at $18-20 trillion. Her heavy emphasis on cost, though, leaves the implicit suggestion that Sanders would be right on these policies if we could afford them. And that may not be a winning message to a primary electorate. —Yoni Appelbaum

10:00 pm: Ah, the domestic policy section of the Democratic debates: the most boring time. The candidates all agree on the ultimate direction; they just disagree on the degree. (In this way, it's like asking the Republicans about Obama's Middle East policy: Whatever else they disagree about, they all know they hate it.) All three candidates want better health care, higher taxes, and cheaper higher education. —David Graham

9:58 pm:

Atlantic Contributing writer Norm Ornstein points out that talking about rising health-care costs doesn't make a whole lot of sense without discussing the relative rate of the increase. —Yoni Appelbaum

9:52 pm: Sanders reiterated his line that he doesn’t have a super PAC. And, so far, it hasn’t kept him from garnering support—including some super PACs which, over his protests, are supporting him. But as my colleague Clare Foran pointed out earlier this week, this may eventually pose as a challenge as he keeps to that pledge and attempts to win the Democratic nomination. —Priscilla Alvarez

9:51 pm: This is where Sanders thrives. Hillary offers a nuanced defense of her approach to financial services regulation, and criticizes some of Sanders’s votes. But it’s just not plausible, and not consistent with her other attacks, to imply that Sanders isn’t interested in regulating commodities futures trading. “I helped lead the effort…against Alan Greenspan, against a guy named Bill Clinton—maybe ya know him, maybe ya don’t—against the Republican leadership...” he thunders back. Big cheers. —Yoni Appelbaum

9:49 pm: Brutal split screen: Hillary Clinton is laughing merrily, while O'Malley looks ready to pop a vein in his neck. Clinton may have likability problems, but she's much better at this than either of her rivals on stage. —David Graham

9:48 pm: It was, of course, cute when Hillary said "everybody should" love her, and a good line when Bernie said about whether corporate America would like his presidency, "No, I think they won't." But it speaks to a basic philosophical difference between these candidates. Hillary believes it's possible for a rising tide to lift all boats, for compromises to benefit everyone, and for all sides to get along. Bernie fundamentally believes in class warfare—a zero-sum game in which, for the lives of the poor to improve, the lives of the rich must be diminished. —Molly Ball

9:43 pm: Clinton's press secretary Brian Fallon, who's never afraid to tweet his displeasure, doesn't seem annoyed at the empty-podium optics. He noted on Twitter minutes ago that his boss "knows how to make an entrance." —Nora Kelly

9:42 pm: Just did the math and Bernie Sanders's plan to spend $1 trillion to create 13 million jobs = $77,000 per job. —Molly Ball

9:41 pm: Hillary throws in a reference to the remarkable saga of Market Basket—in which employees took sides in an internecine struggle for control between Arthur T. and Arthur S. Demoulas, and kept the New England grocery chain as a business built on the welfare of its employees, and not maximizing profits alone. —Yoni Appelbaum

9:40 pm: The first question after the break is on raising incomes for middle-class families. This is where Sanders is most comfortable. The Vermont senator has built a campaign focused on income inequality and it showed in his impassioned response. —Priscilla Alvarez

9:38 pm: Among the demands made by the Republican candidates during their short-lived debate revolt was that networks promise not to “show an empty podium after a break (describe how far away the bathrooms are).” One suspects the Clinton campaign would like to make the same request. —Yoni Appelbaum

9:37 pm: Hillary makes a belated return to the stage. Just a one-word statement on her absence: "Sorry."

9:34 pm: I would have loved it if they had Chris Berman out doing highlights from Tuesday's debate during the intermission, though. "Donald Trump could go all... the... way!!!!" —David Graham

9:32 pm: Give ABC credit for innovation. In addition to starting almost half an hour after the announced time, they also give us two minutes of meaningless banter between commentators, in the style of a halftime show. But if viewers wanted that, they could change the channel and watch a bowl game, instead. —Yoni Appelbaum

9:28 pm: O'Malley interjects into the war conversation with a question that drew loud murmurs from the crowd: "May I offer a different generation's perspective on this?" He's obviously the youngest candidate on the stage, but it reads as disrespectful. —Nora Kelly

9:28 pm: Watching this exchange between Sanders and Clinton, you can see the real dilemma facing Democratic voters. Do you vote for a guy with an obviously shallow understanding of foreign policy? Or do you vote for a woman with a powerful command of the issues who nonetheless is far more hawkish than most Democrats? —David Graham

9:27 pm: Assad has killed 250,000 Syrians, says Hillary. He’s the reason for the mess we’re in. “When we look at these complex problems, I wish it could be either/or,” she says. Her mastery of the intricacies of the conflict is on clear display tonight, as Sanders repeatedly falls back on general principles. —Yoni Appelbaum

9:24 pm: Well, Sanders’s earlier support for a coalition with Russia becomes a little clearer as he says that he wants to focus on destroying ISIS even if that means leaving Assad in power for now, with a transition through democratic elections somewhere off in the hazy future. —Yoni Appelbaum

9:24 pm: Bernie Sanders on the questionable virtues of regime change sounds very much like Rand Paul in the last GOP debate. —Molly Ball

9:22 pm: The exchange between Clinton and Raddatz was very illuminating. Raddatz pressed Clinton on a question asked of Republican candidates this week: Would you shoot down a Russian plane in the no-fly zone? Clinton said she wasn't sure. Raddatz asked whether she ought to know. Clinton then launched into a detailed answer about why she thought a no-fly zone both wouldn't cause tension with the Russians, and why proposing it put pressure on the Russians. I'm not sure it's an entirely credible case, but it is one of the most elaborate, agile, and nuanced foreign-policy arguments we've heard in any debate so far. —David Graham

9:21 pm: Really smart and aggressive questioning by Martha Raddatz here. What's the point of a no-fly zone if your enemies don't have aircraft? —Molly Ball

9:20 pm: That’s true, David! In the run-up to the Iraq War, Bernie Sanders joined with Dennis Kucinich (remember him?) to rally in support of a federal Department of Peace. Sanders keeps touting his opposition to the Iraq War tonight, but somehow, he hasn’t yet mentioned that. —Yoni Appelbaum

9:19 pm: O'Malley's proposal to raise the head of USAID to Cabinet level is the new Department of Peace. —David Graham

9:18 pm: O’Malley’s response to ISIS includes making the USAID administrator into a cabinet member. That’s quite a contrast to the GOP debates, in which candidates want to eliminate so many cabinet agencies they can’t even remember them all. —Yoni Appelbaum

9:14 pm: Sanders' invocation of the need for "Muslim" troops to fight ISIS—rather than local or Arab troops—strikes me as a very strange choice of words. Is the point that ISIS, as messianic Muslims, can only be defeated by other Muslims? Or is it just awkward word choice on foreign policy, never Sanders' forte? —David Graham

9:12 pm: When Sanders says that he wants an international coalition including Russia to intervene in Syria, he seems not to acknowledge that Putin’s goal—propping up Assad—and America’s stated aims—ousting Assad and destroying ISIS—are not actually compatible. —Yoni Appelbaum

9:10 pm: Martin O'Malley has been talking about how the U.S. should welcome more refugees since before it was a topic in the campaign. He still can't get much traction, even as the other candidates move his way. That seems telling about his campaign's struggles with timing and attention.—David Graham

9:09 pm: This is a good question, though, because it forces Clinton to reckon with the position of New Hampshire Governor Maggie Hassan, one of the few Democrats to say she didn't want Syrian refugees in her state. —David Graham

9:08 pm: Clinton doesn't seem to think we need more vetting for refugees, but she can't say that for political reasons, so she's delivering a long soliloquy about how the vetting has to be good. —David Graham

9:07 pm: O'Malley comes close to quoting Benjamin Franklin while answering a question about drawing the line between national security and personal security: "I believe that we never should give up our freedoms in exchange for a promise of security." (Worth noting that the Franklin quote doesn't quite mean what O’Malley uses it to mean here.)

9:06 pm: Clinton is presenting a kinder, gentler framing of the argument that tech companies need to cooperate more with law enforcement. —David Graham

9:04 pm: Bernie’s answer on Trump—that his supporters are right to be upset, but have been misled about what’s really to blame for their troubles—nicely illustrates the strengths and weaknesses of his message. He offers his own roster of villains, and a message many find compelling. But he’s also stuck telling a great many Americans that they’re dupes who don’t understand the world. —Yoni Appelbaum

9:02 pm: Amazing Sanders pivot: Given a question about national security, he's talking about income inequality within about five sentences, switching from anxiety about terror to anxiety about economics. Basically, Sanders is saying that discussions of immigration are a way of cultivating false consciousness in the working class and distracting from the rich getting richer. —David Graham

9:01 pm: Muir asks Clinton if voters who want to ban Muslim immigrants are wrong. She says they're understandably upset, and she explains why she disagrees. But why won't she say, straightforwardly, that they are wrong? —David Graham

9:00 pm: After having failed to enforce the rules and shut down O’Malley’s attack, the moderators serve up a softball to Clinton. How does she feel about Trump’s attacks on Muslims? She takes full advantage. In sports, that’d be a make-up call. —Yoni Appelbaum

8:59 pm: During the last debate, Sanders and O’Malley hit Clinton on her record. But so far tonight, it appears the tables have turned and it’s Clinton and Sanders defending against O’Malley. —Priscilla Alvarez

8:58 pm: I can't imagine that Clinton is upset to be standing calmly on stage while O'Malley and Sanders hoot and holler furiously on either side of her. —David Graham

8:55 pm: Martha Raddatz has done her homework. She asks O’Malley whether he’d support confiscating the millions of assault weapons already out there, and if not, how much difference an assault-weapons ban would make. He points to the purchase before the San Bernardino attack, but clarifies he doesn’t support confiscation. —Yoni Appelbaum

8:54 pm: First big moderator-candidate rumble: O'Malley streamrolls David Muir to get a chance to swipe at both rivals for changing their positions on gun control. —David Graham

8:53 pm: First mention of Donald Trump tonight comes from Clinton, who says the "rhetoric coming from Republicans…fans the flames of radicalization." —Priscilla Alvarez

8:52 pm: ... And you can tell it's a good question because Clinton is entirely declining to answer it. —David Graham

8:52 pm: Hillary tries doggedly to dodge the question. As I noted before, she's well aligned with the Democratic primary electorate on gun control—but not with New Hampshire Democrats, and not with the electorate at large. She keeps talking about radicalization, instead. —Yoni Appelbaum

8:50 pm: Great question from Martha Raddatz, who points out that while all three Democratic candidates favor stricter gun laws, many Americans now believe that more guns create more safety. —David Graham

8:49 pm: Clinton and Sanders air their responses to ISIS, and it’s hard to find much difference between them—other than the different backgrounds they bring. —Yoni Appelbaum

8:45 pm: But then Bernie apologizes to Hillary—sort of like with the emails, he never seems to want to take the attack all the way home. —Molly Ball

8:44 pm: O’Malley jumps on the “bickering” over the data breach, which, according to him, has distracted from issues like terrorism and economic issues. —Priscilla Alvarez

8:44 pm: I see this data issue largely as an opportunity for the Sanders campaign: It had sort of fallen off the radar thanks to Clinton's increasing air of inevitability, but now, by loudly crying that he's been screwed by the DNC, he's able to reanimate his anti-establishment message. —Molly Ball

8:42 pm: In the first debate, Sanders passed up the chance to go after Clinton over her emails, stressing that there were more important issues to discuss. Hillary, given the opportunity to criticize his campaign over the data breach, she returned the favor. (And Bernie, a moment later, draws the parallel himself.) —Yoni Appelbaum

8:40 pm: Bernie “Yes, I apologize…Not only do I apologize to Secretary Clinton…I want to apologize to my supporters. This is not the type of campaign that we run. And if I find anyone else involved in this, they will also be fired.” —Yoni Appelbaum

8:40 pm: Sanders blamed the vendor for letting down the firewall, but acknowledged that "our staff did the wrong thing." He called the DNC shutting off his campaign's access to data "an egregious act.” —Nora Kelly

8:39 pm: That didn’t take long. The very first question goes to Sanders, and it’s about the NGP VAN data breach. —Yoni Appelbaum

8:38 pm: This debate was billed as being about national security, but true to form, Sanders' opening statement stays focused on his core economic issues: inequality, wages, climate change, campaign finance. —David Graham

8:37 pm: Tonight I feel as though I represent the demographic the DNC had in mind when it scheduled this debate: I am a swing voter with family obligations to attend not one but two Christmas parties, rendering me unable to tune into the debate. Since this marks the second time the Democrats have debated on a Saturday evening, there can be little doubt that aiming for minimal viewership is deliberate. This may or may not be an effective political strategy. Either way, I find it civically objectionable. Hillary Clinton has an enormous advantage due to her name recognition and ability to raise funds. To contest the nomination Bernie Sanders must leverage the few shared civic moments of voter deliberation to great effect. The DNC's scheduling robs him of those moments, and its effect is fairly described as anti-Democratic. I'd go into more detail, persuading you all to punish the DNC for this behavior, but I see that the supply of shrimp on the tray across the room is waning, and my mom is giving me dirty looks for being on my phone, so it looks like their strategy is going to work. You got me this time, DNC. —Conor Friedersdorf

8:36 pm: Hillary Clinton says she looks forward to discussion of "real issues" during the debate. Does that mean no first strike on NGP VAN? Or no engagement on it all? —David Graham

8:35 pm: O’Malley says that it’s a different debate tonight “because tonight is different because of this reason.” He’s trying to talk about the aftermath of terrorist attacks in San Bernardino and Paris, but it takes him a while to get going. —Yoni Appelbaum

8:32 pm: Martin O’Malley has been struggling in the polls, far behind Clinton and Sanders. And ABC’s intro for the debate was a clear show of that for anyone that hasn’t taken notice. O’Malley barely made an appearance; it framed the debate as a fight between Clinton and Sanders. —Priscilla Alvarez

8:28 pm: One challenge facing Clinton tonight is how very different Democratic voters in New Hampshire are from those in the rest of the country. I noted, below, that it’s a remarkably white electorate. But it also differs in other ways. Hillary has successfully attacked Bernie Sanders on gun control in the past; he’s out of step with his party’s primary voters on that issue. But it’s different in New Hampshire, where a CNN/WMUR poll recently found 43 percent side with Sanders, and just 34 percent with Hillary. So she’ll have to thread the needle tonight, speaking to the millions of voters who are tuning in, without alienating the Granite State voters she’s trying to win over. —Yoni Appelbaum

8:15 pm: Polls consistently show plummeting trust in the media. Announcing an 8 p.m. debate, and then using the first 15 minutes to have talking heads grab viewers’ attention surely doesn’t help. —Yoni Appelbaum

8:06 pm: As Yoni noted in his intro, the caper of the Sanders database bust is expected to be a major topic of discussion tonight. This is a pretty arcane dispute, at base; the best explanation I've read is from ​The Washington Monthly. As the candidates tangle, think about what the chances are that any of the candidates on stage could describe the actual mechanics of the breach in any kind of accurate detail. My guess: Very low. —David Graham

8:01 pm: The Sanders camp charges that the Democratic National Committee and its chair, Debbie Wasserman Schultz, set up the debate schedule to protect Clinton’s frontrunner status. Compared to the GOP field, the Democrats have fewer meetings, and those they have are scheduled for times when viewership is likely to be lower. But the Sanders campaign’s breach of Clinton data files has put Sanders back into the headlines on the eve of the debate—greatly aided by the DNC’s harsh response, from which it subsequently backed away. If Wasserman Schultz was trying, in both instances, to help Clinton—as the Sanders campaign charges—than her efforts seem to have worked at cross-purposes here. If viewership is up, as expected, then Jeff Weaver should send her a particularly nice thank-you note. —Yoni Appelbaum

Hillary Clinton, Martin O’Malley, and Bernie Sanders square off for the third time at 8 p.m. on Saturday night, at St. Anselm College. Their only New Hampshire debate this cycle will focus on national security and foreign policy. And if you’re wondering why three Democratic candidates are debating late on a Saturday night in the middle of college football’s bowl season, you’re not alone.

The Sanders campaign emailed its supporters on Friday to claim that its success had led “the Democratic National Committee to place its thumb on the scales” to support Hillary Clinton. “You see that fact evidenced in their decision to bury the Democratic debates on weekends during nationally televised football games. It's more or less an open secret.”

That charge resonated with Bernie’s legions of supporters and donors. It helped the campaign haul in another $1 million in the next day, punctuating the most dramatic stretch the Democratic campaign has yet seen.

It started with four Sanders staffers, who found a flaw in the NGP VAN voter database that the Democratic National Committee rents to campaigns, and used it to run two dozen searches of the Clinton campaign’s data. The Sanders campaign quickly fired Josh Uretsky, the leading staffer involved, but provided shifting explanations of what had occurred. The DNC, in response, shut off the Sanders camp’s access to NGP VAN, which is vital to the campaign’s operation.

The campaign quickly struck back, calling a press conference to accuse the DNC of holding “data hostage” in an effort to “attack the heart and soul of our grassroots campaign.” It also filed a lawsuit. Late on Friday night, the DNC restored its access, leading the Sanders camp to crow that it had “capitulated.” The incident left Clinton staffers charging foul play, Sanders supporters feeling aggrieved, and the DNC looking singularly inept.

It seems unlikely, though, that it will do much to alter the broad arc of the race. Clinton still sports a commanding lead in national polls; a Public Policy Polling survey released on Thursday showed her with 56 percent support, with Sanders at 28 and O’Malley at 9.

But national polls are of limited relevance at this stage; there’s no national primary. Candidates have to prevail in a series of state-level contests, and New Hampshire voters have made a habit of going their own way in their first-in-the-nation primary. Sanders leads Clinton, 48 to 46, in the most recent poll, with O’Malley scarcely registering at 2 percent.

The independent senator from Vermont enjoys a number of advantages in the neighboring Granite State. Proximity has given him a strong understanding of local issues, helped him build a ground-level organization, and made voters more comfortable with his candidacy. A recent CNN/WMUR pollin the state found 60 percent rated Sanders “most likeable,” and 68 percent “most progressive.” He has struggled elsewhere to connect with black and Hispanic voters, but in 2008, 95 percent of New Hampshire Democratic primary voters were white.

One big challenge, for Sanders, is that scarcely a quarter thought he had the “right experience to be president,” and a scant 17 percent gave him the best chance to prevail in the general election.

Clinton faces her own challenges, though. That same poll found 46 percent rated Hillary Clinton as “least honest;” just 3 percent chose Sanders. Voters trusted Clinton to tackle ISIS, but Sanders to take on big banks and address income inequality. The resurgence of national-security concerns may help Clinton, but tonight, she’ll also be trying to persuade local voters that she understands, and can address, their economic anxieties.

O’Malley, meanwhile, is fast running out of time, and perhaps just as crucially, cash. The former Maryland governor has failed to break through thus far, and the timing of this debate is unlikely to help him.

All sides in the Syrian civil war have, to some extent, strategically engineered mass movements of civilians into and away from their areas of territorial control. In some cases, the systemic depopulation and repopulation of territory represent attempts to gain tactical military advantage. For example, in early October Amnesty International reported that the Democratic Union Party (PYD), a Kurdish rebel group in Syria, was demolishing homes and displacing entire villages in order to, as Mao would have put it, “drain the sea [the civilians] in which the fish [the enemy] swims.” The PYD is not alone. This kind of engineered migration has long been a tool of warfare, since noncombatants can provide safety, succor, and support and serve as a source of recruits.

Conversely, civilians may also be prohibited from fleeing areas controlled by combatants, in order to shield soldiers and their supporters from military attack. Human Rights Watch reported in early November, for instance, that the rebel group Jaysh al-Islam has been keeping civilian hostages in northern Syria in order

Demographics and the Nature of Future Conflict

Current demographic trends will affect the nature and conduct of future armed conflicts by influencing the physical environment of future conflicts, and by creating new strategic instruments of conflict. These developments will now be dealt with in turn.

The Increasingly Urban Context of Future Conflict

Increasing urbanization in Asia, Africa, the Middle East, and Latin America has implications for the nature of future conflict, both high and low intensity. Relatively more conflict will take place against an urban backdrop, and this will create challenges for U.S. ground forces operating in the developing world.

At the high-intensity end of the conflict spectrum, rogue regional powers that wish to engage the United States in conventional warfare will see urban areas as a natural impediment to the execution of standard U.S. joint military doctrine. The U.S. military's technological advantages in long-range precision fires and information processing will be largely nullified in cities by restrictions on movement and line of sight as well as by the likely presence of large numbers of civilians, some of whom may even be used as human shields by the adversary. An example of the severe challenges posed to modern armies by skilled opponents taking advantage of urban terrain is found in the 1994-95 Battle of Grozny. In Grozny, the outnumbered and technologically inferior Chechens exacted a very heavy toll in casualties from the attacking Russian forces.[1] Indeed, the clumsy and ruthless manner in which the Russians finally captured the city helped to turn Russian public opinion against the Chechen War and thus paved the way for Russia's ultimate military defeat in that conflict.

In the realm of low-intensity conflict, there are also reasons to expect more urban conflict in the future. The increase in the proportion of national populations in the developing world residing in cities means that urban areas will likely become even more important political centers of gravity than they have been in the past. A greater fraction of the core economic and political activities of developing states will be taking place in cities in the future. Furthermore, the ongoing process of urbanization is accompanied by a discrediting of the Maoist insurgency doctrine that favored rural over urban insurgent activities. This doctrine was very popular in the 1950s and 1960s but has now lost much of its appeal to insurgents and warlords throughout the world. Furthermore, empirical research tells us that combined rural/urban insurgencies have had a much greater rate of success than purely rural insurgencies.[2] Finally, the squalid living conditions in the rings of slums that now surround many large Third World cities are becoming a fairly permanent condition. Many of the recent migrants live in these areas and their desperate straits can prove to be fertile ground for radical and revolutionary groups that seek new recruits for their battle against the existing regime.

All of the above realities create incentives for insurgent groups to conduct at least a portion of their campaigns in cities. Sometimes the urban portion of an insurgent campaign may consist mainly of sabotage and terrorism against government targets and/or foreign military personnel. In other cases, however, insurgents may make efforts to bring sizable portions of an urban area under their direct control and perhaps even erect a shadow government in those areas.

Rural insurgency will clearly not fade away as a strategy employed by revolutionary groups despite the proliferation of large urban areas in the developing world. Instead, to be successful, relatively more insurgent groups will find that simultaneous urban and rural operations are necessary complements. It is also important to note that the increasingly urban nature of future conflict is not necessarily due to any higher propensity toward violence among urban dwellers as opposed to people who reside in rural areas. Indeed, there is little conclusive evidence suggesting that the phenomenon of urbanization per se creates a greater proclivity toward political/civil violence.[3]Instead, the argument being made here is that the physical character of urban environments and the strategic opportunities they present as a result of long-term and ongoing demographic trends will create incentives for the leaders of both regional powers hostile to the United States and insurgent groups to base more of their military operations in the built-up terrain of urban areas.

New Strategic Instruments of Conflict

Demographic patterns and shifts are increasing the importance of two "nontraditional" instruments of conflict: ethnic diasporas and renewable resources. Scholars working within the dynamic paradigm of demographics and national security are pointing to these instruments as potential sources of leverage in military campaigns throughout the world.

Ethnic diasporas. Ethnic diasporas have existed in one form or another since ancient times, but advances in transportation and communications over the last 20-30 years have increased their size, visibility, and impact within the international system.[4] Specifically, improvements in the accessibility and speed of long-range transportation have permitted larger migratory flows into developed regions such as Western Europe, thus increasing the size of diasporas abroad. The ongoing communications and information technology revolution now allows the more activist elements within these larger immigrant communities, if they can mobilize themselves, to have more rapid and visible means of calling attention to issues of interest in their home countries than ever before. Some of the more significant of today's ethnic diasporas are the Armenians in France and the United States; the "overseas Chinese" in Southeast Asia; the Indians in Western Europe, North America, Fiji, and East Africa; the Tamils in Canada and Western Europe; the Iranians in Western Europe and the United States; the Russians in Central Asia, Ukraine, and the Baltic states; and the Jewish diaspora in the United States, Canada, Europe, and Latin America.

Today, within ethnic diasporas there are activist groups that could become a strategic asset their home countries and territories can draw upon to help them achieve regional politico-military objectives. The growing web of information, communications, and mass media links, including the Internet, international TV news networks, and global banking nets, increases opportunities for globally distributed ethnic diasporas to play a key role in military campaigns involving their home state or territory. This can be done through extensive fundraising for the purchase and transfer of arms, an international public relations campaign to demonize opponents of the home state, or the exertion of pressure upon governments in host countries to turn against the enemies of their home state or territory.

Examples of diasporas acting as a strategic force in regional conflicts can be readily discerned. The sudden upsurge in strength of the Kosovo Liberation Army (KLA) during the summer of 1998 at the expense of more compromise-oriented Kosovo elites may have been at least partially due to fundraising efforts by the Albanian diaspora in the West. It is probably too early, however, to know what the lasting effect of diasporan activities in this case will be. The Croatian diaspora was quite effective in helping swing the international community behind the Croats in their conflict with the Croatian Serbs in the mid-1990s. Armenian migrs in the United States have been working hard in the past two years to compel the U.S. government to halt both its diplomatic overtures to the government of Azerbaijan and its efforts to help U.S. oil companies secure exploration and drilling contracts in that petroleum-rich Caspian state. The object of these moves is to weaken the long-term potential of the future Azerbaijani military threat to landlocked, resource-poor Armenia. Finally, the Tamil diaspora in Canada and Western Europe has been active in funneling financial support to the Tamil insurgents fighting Sinhalese government forces in Sri Lanka.

As time goes on, some key diasporas will acquire even more influence upon the military balance in their home regions. One could even imagine cases where rival diasporas themselves engage in violent conflict in their host countries in order to advance the causes of their respective home states. At any rate, American diplomatic, intelligence, and defense policymakers will have to consider ever more carefully the impact of ethnic diasporas upon regional wars in the next 10-20 years as they become more involved in supporting the military postures and campaigns of their home states.

Renewable resources. Political scientists have long recognized that sources of nonrenewable resources (such as oil and minerals) are an object of geopolitical competition between states. In addition, blockades and embargoes of nonrenewable resources have been used in times of war to weaken the position of states, like Wilhelmine Germany and Imperial Japan, that are not well endowed in such resources. Recently, however, scholars like Peter Gleick have begun pointing out that renewable resources, like water, are also becoming relatively usable as instruments of coercion in wartime.[5] Demographics is a key part of this emergence because an increasing number of pivotal developing countries in geopolitically important regions like the Middle East are experiencing population growth rates that are straining their water supplies. Such states thus become especially susceptible to wartime coercive pressure from neighboring adversaries who are better endowed with water. In the 21st century, more and more armed conflicts in arid regions may feature the "water weapon" being used as a strategic instrument of coercion against wartime enemies whose demographic profiles have created conditions of domestic water scarcity.

When surveying the globe's high-population-growth flashpoints, one can quickly find several places where the geography of regional water supplies creates opportunities for a local military power to use water supply constriction as an instrument of military coercion. One of the most notable is the Euphrates River region in southern Turkey, Syria, and northern Iraq. Turkey's Grand Anatolia project to increase hydroelectricity production with the construction of new dams will restrict the flow of Euphrates water to Syria by 40 percent and to Iraq by 80 percent; this project will also grant the Turkish government the latent ability to cut off all Euphrates water to Syria and Iraq if it so desires.[6]While this option has not yet been exercised, it is a potent card that Ankara could someday play in the event of war with either Syria or Iraq over the thorny Kurdish question, since population increases in these states are creating a looming condition of water scarcity. The seriousness of any river water cutoff for these two Arab states is demonstrated by data indicating that 79 percent of Syria's surface water and 66 percent of Iraq's surface water is imported from outside their borders.[7] Another zone of relative water scarcity with major security issues is the Nile River region in northeastern Africa. Egypt is almost totally dependent on the Nile for its water supplies, and Egypt's burgeoning population is already placing pressure on the existing yearly flows of river water. The problem for the Egyptians is that the Nile's runoff originates in several Central African nations located to the south of Egypt, not all of which have had placid relations with Cairo in the past. Of special concern to the Egyptian leadership are the future actions of Sudan on the water issue. Sudan is an Islamic fundamentalist state that may have ambitions to constrain Egyptian power and influence in Africa. In any future Egyptian-Sudanese war, Sudan's control over at least a portion of the Nile "spigot" would cause headaches for Egypt's military leaders. Egypt's position as a major American ally in the Middle East makes this scenario worthy of some scrutiny in Washington.

Table 2 shows how per-capita water consumption in many Middle Eastern countries is declining.

Outside of the Middle East, another region of strategic importance that faces both demographic pressures and water shortages is Central Asia. The five Central Asian states that surround the Aral Basin will see their cumulative population rise from 54 million in 1994 to 86 million in 2025.[8]Fresh river water shortages are being created by the large irrigation demands of the local cotton crop and contamination caused by the haphazard use of agrochemicals. Some of the most water-stressed areas are in the Ferghana Valley, which is shared by Tajikistan, Kyrgyzstan, and Uzbekistan. In any future conflict between these states, water sources could become a major object of military strategy.

We cannot dismiss the possibility that renewable resources will become more salient as instruments of wartime coercion. High rates of population growth in several strategically important Middle Eastern states have increased pressure on already meager water supplies, much of which already originate outside their borders, making them relatively more vulnerable to the "water weapon."

At the moment it appears that urbanization should be of greater concern to American military planners than either militarily active diasporas or the potential use of water as a strategic weapon. This is because urbanization will have the greatest direct impact upon American power-projection operations in the future. For the U.S. foreign policymaking community more generally, however, the water issue may well become the most salient in this category as time goes on.

Demographics and the Sources of Military power

Between the days of Napoleon's mass armies of French citizens in the late 18th century and the mid-1980s, most analysts believed that quantity counted for much in modern warfare. In the Industrial Age, the predominant paradigm of warfare was large conscript armies with plenty of reserves battling each other over long, continuous fronts. The European campaigns of World War I and II are the clearest examples of this paradigm of war in action. Combat models of the Industrial Era emphasized force-to-space ratios and the density with which an army could populate each sector of the front as the key metrics for determining how a given battle was progressing.

Now, however, the results of Desert Storm and the ongoing discussions about a contemporary Revolution in Military Affairs (RMA) that features vastly improved sensors and information-processing capability are causing many to reassess the old paradigm of war and to search for new metrics of combat effectiveness. It is not clear that larger armies enjoy as much of an advantage on the modern battlefield as they once did. This has implications for both high-population-growth and low-population-growth states.

Low-Growth States

Low growth has two great military implications for those states that face it. First, shrinking youth cohorts mean that the military forces they can put into the field will become progressively smaller in terms of personnel. This is probably not critically dangerous in and of itself, since as we saw above, there is reason to believe that numbers may matter somewhat less on future battlefields. Second, increasing numbers of elderly citizens at the top of the age distribution will demand increasing amounts of government funding for pensions, medical care, etc., and this could well crowd out significant amounts of defense investment. Indeed, the recent work of Peter Peterson shows that by 2040, the cumulative public pension deficit of the G-7 industrialized states (a group that includes a number of countries with very low population growth) will equal about 12 percent of those nations' total GDP.[9] Fiscal challenges such as these will undoubtedly reduce the amount of money available for defense expenditures over the long run in the major NATO nations of Western Europe and Japan.

As such, the sources of military power in low-growth states will shift from manpower-intensive forces to capital-intensive forces.[10] Many European states are already moving away from large conscript armies designed for territorial defense and toward smaller, professional forces focused more on expeditionary operations on the European periphery. These forces will be kept at a higher level of readiness than the old territorial defense forces. Smaller force structures will free up some operations and maintenance funds for investment in new weapon systems. Germany is the one major exception in this area, as Berlin continues to hold on to the notion of a conscript army. But both Britain and France are moving clearly in the direction of smaller, more capable, and more deployable military force structures. Britain's recently completed Strategic Defense Review mandated a leaner, more technologically advanced force that is better able to operate in multinational coalitions. France, under the Jospin government, is moving forward with efforts to end conscription and cut back the number of its uniformed military personnel from 502,000 to 352,000.

Also, investments in human capital will become relatively more important to low-growth militaries. With fewer soldiers available, the levels of training and experience in the force will become critical to battlefield performance. The value of each individual soldier, sailor, and airman to these militaries will increase as long as national youth cohorts remain relatively small.

The skyrocketing costs of advanced new military procurement projects such as modern fighter aircraft, surveillance and reconnaissance satellites, tactical communications systems, precision-guided munitions, and long-range sensors make it likely that more and more low-growth countries will seek to leverage multinational cooperation to maintain their military power. In the major low-population-growth area of the world--Europe--there will have to be an acceleration of current trends toward multinational procurement and multinational force structures if the West Europeans are to retain great military power. This is because the demands of supporting increasingly elderly populations will crowd out much of the funding individual European nations would need to purchase and support advanced new weapon systems on a national basis. If the West Europeans are unable to successfully substitute capital for manpower in their force structures, invest wisely in the human capital that remains, and solidify multinational defense linkages, then their military capability may decline in the next 10-20 years.

High-Growth States

High-growth states in Africa, Asia, and the Middle East face a different set of problems. They have a surplus of youth for their armed forces; their concerns are with quality of the force rather than quantity. The need to train a very large cohort of personnel 18-20 years old each year for military service can dilute these organizations' ability to field, maintain, and operate the types of advanced, integrated weapon systems often necessary for success in modern conventional warfare.

There are three imperatives driving various high-population-growth nations to maintain large standing armies. First, there is often an economic need to draft large numbers of youth each year to keep the unemployment rate at an acceptable level and preserve social stability. Second, many developing nations see the army as not only a combat instrument but also a vehicle for imbuing young people with a spirit of pride and faith in their nation; armies can be a tool for increasing social cohesion, especially in states with multiethnic populaces. Third, there is the internal security function. Some developing states need large armed forces and paramilitary auxiliaries to preserve order and protect the regime from insurrection.

Many developing states will deal with the conflicting demands of domestic politics and military quality by creating bifurcated force structures in which perhaps one-half to three-quarters of the force is made up of low-quality infantry units designed mainly for the purpose of internal policing and/or static defensive duties in wartime. The top one-quarter to one-half of the force structure will be made up of elite units designed for conventional warfare or complicated counterinsurgency operations. These units will more often than not be made up of career officers and long-serving enlisted men who have special ties and loyalties to the regime; they will usually be paid much better than the rest of the force. One case of this is the Iraqi Army in both the Iran-Iraq War and Desert Storm. The bulk of the force was made up of fairly low-quality infantry brigades that were used only to man defensive fortifications, while all operations that required offensive maneuver were carried out by the elite Republican Guard divisions. Thus, although many developing states will maintain large armies on paper, their real combat power in conventional wars will be contained in a relatively small number of elite formations.

Demographics and the Sources of Conflict

Demographic shifts can cause conflict in two major ways: by directly causing increased tensions between states in a region, or by altering the domestic politics of a given state so that it becomes a security problem for its neighbors.

Demographics and Regional Security

Demographic shifts can increase tensions between neighboring states and thus increase the risks of war. Tensions can increase as a result of three factors: differential population growth rates and sizes with tangible military implications, flows of migrants and refugees across international borders, and resource competitions in areas facing population pressures.

Differential population growth rates/sizes and regional balances of power. Under certain circumstances, differences between neighboring states in population growth rate or size can change the existing conventional military balance of power, increasing the risk of regional instability and war. There are two mechanisms by which this could occur. First, the state whose faster-growing population or greater size is allowing it to field more conventional military capability could attack its neighbor in the belief that it will be relatively easy to win a quick and decisive military victory. Second, the lower-growth or smaller state could seek to launch a preemptive attack upon its neighbor to take advantage of a window of opportunity where the regional military balance is still somewhat in its own favor.

But for simple differential population growth rates or population size to overturn an existing regional balance of power, four conditions need to hold: the competing nations are adjoined primarily by land (as opposed to maritime) borders, nuclear weapons are not present in the region, the state with a faster-growing or larger population has the ability to convert its demographic strength into increased conventional power, and the local territorial profile is conducive to offensive operations.

Pure population size is easier to convert into conventional military power if the two competing nations face each other across land, and not maritime, borders. This is because increased numbers of military personnel have a greater relative impact on ground operations than on air or naval operations. Armies benefit more from advantages in numbers of personnel over their opponents than do air forces and navies. Air forces and navies rely more on technologically oriented systems (combat ships, fighter aircraft, early-warning aircraft, surface-to-air and surface-to-surface missiles, advanced command and control architectures) than quantities of people in the field to achieve their combat objectives. Two contemporary cases illustrate this point: the China-Taiwan military balance in the Taiwan Straits and the Greek-Turkish competition in the Aegean Sea.[11]Both situations exist in a primarily air/naval theater of operations, and in both we have a tremendous disparity in population size and growth between the antagonists. Nevertheless, the fact that these competitions are taking place primarily across maritime boundaries allows the smaller states to keep pace by maintaining an adequate number of technologically advanced air force and navy systems in their inventories. Thus, both Taiwan and Greece maintain solid deterrent postures despite their smaller population size and growth rates, and this allows some semblance of balance to remain in these theaters.

Demographic shifts are not likely to lead to sudden changes in a regional balance of power if survivable nuclear arsenals are present on both sides in the region because the risk of nuclear escalation during a conventional war would probably be enough to deter either party from a conscious act of aggression. Wars can still occur in such regions as a result of inadvertent escalation over issues like border disputes and provocative exercises, but conflict will probably not come about as a result of conscious decisions in either state about how demographic factors are altering the military balance of power.

For differential population growth rates or sizes to be decisive militarily, the state with more growth or larger size has to be able to convert its greater population strength into concrete conventional military power. This is not easy. Many states in the developing world that have high population growth rates do not have the financial resources to provide basic services for the additional people, let alone the capability to invest in a conventional military buildup. Perhaps more important, though, is the fact that the ongoing Revolution In Military Affairs (RMA) is making first-class conventional military power far more technology and training intensive than it was two or three decades ago.[12] This holds increasingly true for land power. The enormous investments required to equip and train first-class units will make it very difficult for even populous states to maintain large force structures. Indeed, several of these large states (e.g., China and Russia) have made conscious decisions in recent years to slim down the size of their armies to free up funds for more advanced weaponry. In short, as we move into the 21st century, it will be harder and harder to use raw numbers to achieve real increases in conventional military power. This is illustrated by the case of Israel and its Arab neighbors. Rapid population growth since the 1960s in Egypt, Syria, and Iraq has placed Israel in a position of chronically increasing demographic inferiority in the Middle East; yet the inability of most of Israel's Arab neighbors to translate their population growth into greater conventional power, coupled with America's military aid program to Israel, has allowed the Middle Eastern military balance to remain consistently favorable to Israel.[13]

Finally, the territorial profile of a region has to be suitable for rapid offensive conventional military operations if demographic shifts are to be able to overturn the existing balance of power. Aggressor states traditionally seek quick victories when they invade their neighbors, and if the local terrain significantly favors the defender (i.e., mountains, jungles, wide rivers) or the strategic depth of the defender state is great, then all but the most drastic demographic shifts will not change the local balance enough to destroy deterrence.[14]

A brief survey of the globe reveals that the issue of demographic shifts affecting conventional balances of military power is not one that is likely to create widespread conflict. This issue could become a security problem in only a few key regions. There are two reasons for this. First, there are relatively few land borders between states with vast differentials in population growth. In most regions, the local states have broadly similar population growth rates. For example, the 17 nations that have been estimated as undergoing population declines between 1996 and 2025 are all in Europe.[15]By the same token, 16 of the 20 nations with the highest fertility rates in the world are in sub-Saharan Africa.[16]Second, in most of the areas where high-growth states border on low-growth states, all of our conditions are not met. The border between the low-growth countries of southern Europe and the high-growth nations of North Africa is maritime, so North Africa's faster population growth is muted in terms of its effect on the conventional balance of power there. Land borders do exist between low- to negative-growth Russia and the high-growth Central Asian nations (Uzbekistan, Kazakhstan, etc.), but the technological and organizational state of the Central Asian armies is such that they will not, in the next 10 to 20 years, be able to turn their nation's high growth rates into an increased level of conventional military capability that could overturn the regional balance of power with Russia to their advantage. In the more distant future, it is conceivable that the large Central Asian states could challenge Moscow conventionally, especially if their national scientific-technical establishments were to expand and deepen. There could well be armed conflict between Russia and some of the Central Asian states in the next decade or two, but that conflict will not occur because of perceptions that the long-term conventional military balance of power is changing in the Central Asians' favor. It would instead be driven by other factors. The Sino-Russian border is a third example of a low-growth state juxtaposed against a much larger and higher-growth state, but here both parties have strategic nuclear weapons. Perceptions of low Russian population densities in the Russian Far East could lead to low-level Chinese military probes and low-intensity conflict in the next 10-20 years, but the continued existence of a substantial Russian nuclear arsenal will probably prevent the Chinese from seriously considering the option of launching a conventional military campaign to seize large parts of Russian territory as a result of demographic factors.

Two areas where differential growth rates could indeed change local balances of power in regions where our four conditions hold are Armenia/Azerbaijan and Malaysia/Singapore. Malaysia and Azerbaijan are nations with both significantly higher fertility rates than their neighbors and the technical/economic potential to build improved conventional military power over the long term, Malaysia because of its growing industrial base in the information technologies and Azerbaijan because of its potential oil wealth. These cases notwithstanding, the foregoing analysis suggests that population-driven changes in conventional regional balances of power will not be a major systemic cause of war and instability during the next three to four decades. Other demographic factors, as we shall see below, will probably have a greater potential to cause instability that threatens U.S. interests.

Flows of migrants and refugees across international borders. In the last decade, the movements of refugees and migrants across international borders has had some high-profile political effects. In 1989, the mass migration of East Germans into West Germany through the suddenly open Austro-Hungarian border was the catalyst that brought about the collapse of the German Democratic Republic and the unification of Germany.[17] In 1991, the flow of Kurdish refugees into Turkey as a result of an abortive post-Desert Storm Kurdish uprising against Saddam Hussein led to NATO military intervention in northern Iraq (with UN blessing) to establish a safe zone for the Iraqi Kurds. Instances such as these have, as Myron Weiner writes, catapulted refugee and migrant flows into the realm of "high politics."[18] The security implications of these population movements across borders are increasingly recognized by the academic community. This section will outline the major causes of these flows and then examine their effects on regional security.

Causes of population movements: Population movements can be voluntary or involuntary. Voluntary movements or migrations are usually driven by economic-pull factors, that is, a desire to move from low-opportunity regions to countries where one's income and quality of life can improve. Most economic-pull migrations have been from the world's South to the North. The movement of Turkish guest workers to Germany in the 1970s and 1980s and the movement of Mexican migrants into the southwestern United States in the current day are both examples of economic-pull migrations. High fertility can contribute to these movements, especially if the home country's economy is incapable of providing employment for the masses of youth entering the labor force.

Involuntary, or refugee, flows are usually South-South movements and tend to have more direct security impacts, at least in the short run, than do economic-pull migrations. Involuntary flows can be either controlled or uncontrolled.[19] Uncontrolled flows are due to factors such as land overuse, environmental degradation, resource scarcity, famine, or localized communal violence. These flows are not the result of any conscious political decision made by governments. The movement of Bangladeshi refugees into the Indian state of Assam is an example of an uncontrolled refugee flow, as these people are fleeing regions where population growth is simply overtaxing the available agricultural land.

Controlled flows, on the other hand, are movements that are driven by government policies. Governments induce such flows for three reasons: to preserve cultural homogeneity, to remove politically troublesome groups from the body politic, and to exert pressure on neighboring states.[20]In extreme cases, pressure exertion could actually be a prelude to colonization of new territories by the state sending the refugees. The Vietnamese government's decision to expel large numbers of ethnic Chinese in the late 1970s (the "boat people") is an example of a regime inducing an exodus in order to preserve cultural homogeneity. Saddam Hussein's brutal offensive into the Kurdish regions of Iraq in the spring of 1991 is a case of a regime forcing a migration to expel politically troublesome elements from its territory. Fidel Castro's emptying of Cuban jails to feed the Mariel boatlift to Florida in 1980 is a second case of a refugee flow employed as an instrument of political expulsion. Finally, the communist Afghan government's policy of forcing some rural groups to seek refuge in Pakistan (a policy aided by Soviet occupation forces) during the Afghan Civil War of the 1980s was an effort to destabilize the Pakistani regime in order to compel it to halt its support for the rebels. This is an example of forced refugee flows as a tool for pressure exertion.

Security implications of population movements: Refugee (and sometimes migrant) flows can result in security problems for either the home or the host country.[21] The home country faces the risk that the departed refugees will use the host nation as a springboard to mount political or military actions aimed at weakening or overthrowing the government of the home nation. Refugee groups could even play a role in changing the policy of the host nation so that it becomes an enemy of the home nation. After the victory of the Tutsi-led Rwandan Patriotic Front in the 1994 civil war, Hutu extremists used the vast Hutu refugee camps in Zaire as a base of operations for sporadic guerrilla attacks against the new Rwandan regime. Cuban refugees in Florida have had a major effect upon U.S. policy toward the Castro regime over the last 30 years, causing most American administrations to hold a very hard line against Castro.

Host countries probably face even greater security risks as a result of refugee flows. There are a myriad of possibilities where a large refugee influx could weaken the host nation's security position. First of all, refugee populations burden the infrastructure and natural resources of the host nation, causing economic hardship and accelerated rates of resource usage. Second, if a refugee group has ethnic brethren existing in the border regions of the host country, the new combined ethnic bloc poses a threat of separatism to the host nation. The Turkish government's unease about the influx of Kurds into its already heavily Kurdish southeastern regions in the spring of 1991 is perhaps the classic case of a regime seeing a refugee flow as the precursor to more intense ethnic separatism. In Macedonia today, authorities fear an increased ethnic Albanian exodus from Kosovo for exactly the same reason. Third, if a refugee group moves into a region that is sparsely populated, the host regime has to worry that the refugee group may someday wish to colonize the affected region and perhaps have it rejoin the home state. Some Russian elites see the current movement of Chinese migrant laborers into the Russian Far East in just this sort of light. Fourth, there are cultural identity issues if the influx of refugees or migrants is large enough to change the ethnic composition of the state or region they are entering. The Bangladeshi influx into Assam, for example, has changed the ethnic character of that region drastically and led to serious communal violence with the indigenous peoples in the 1980s that created a security problem for the Delhi government. Another aspect of the cultural identity problem is the risk that large intakes of refugees or migrants will cause a rise in nativist political movements, which often espouse aggressive foreign policies. Fifth, large flows of refugees can create conflict spillover in the host country. The establishment of large Cambodian refugee camps just inside Thailand generated spillover effects for the Thai government to contend with during the 1980s Vietnamese occupation of Cambodia, as Vietnamese security units often swept into the camps seeking out Cambodian guerrilla stragglers during hot-pursuit operations. Spillover effects always raise the specter of an escalation to full interstate warfare.

How do these different security impacts of refugee flows affect American interests? It seems clear that population flows pose a greater risk of instability in regions important to Washington than does the question of demographically induced changes in conventional balances of power. Large influxes of refugees often create highly charged emotions about territorial integrity, ethnic identity, and equitable distribution of resources that can lead to armed conflict between states. Two threats to U.S. security interests are apparent here. First is the risk that some of our key allies in the developing world will be destabilized by population flows. Turkey is a prime example, of course, but one must also consider the case of the new East European NATO members in the event that a Russian economic meltdown generates a wave of refugees moving west into Poland and Hungary. The fragile political institutions of these states would be sorely tested by such an event. Second, we must be cognizant of the possibility that migration issues could generate increased friction between large powers, thus shaking the international system. Russian concern over Chinese migrants in the Russian Far East, for example, could lead to tenser relations between these two large powers over the long run, increasing instability in Asia.

Competition for water in areas facing population pressures. Competition for renewable resources, such as water, in regions where several states face population pressures on their supplies of renewable resources is another potential cause of interstate conflict. We have already seen that the "water weapon" could be an important instrument in future conflicts, and there is a need to explore the possibility that it could be a cause of interstate conflict as well. Many experts point to the case of the Israel/West Bank region, where growing Jewish and Palestinian populations are competing over increasingly scarce aquifers, as an exemplar scenario for future conflict.[22] As we saw earlier in this report, the Nile River and Euphrates River regions are also areas where demographic growth is straining water supplies for a number of countries.

However, a close analysis by Homer-Dixon has revealed that pure competition over renewable resources has not been correlated with the outbreak of armed conflict in the past.[23] Conflict over such resources could conceivably aggravate existing tensions between states over other outstanding issues, but it will probably not be a cause of future wars in and of itself. Renewable-resource disputes are more often a symptom of an already poor bilateral relationship than a driver of poor relations between states.

Overall, we have seen in this section that the greatest demographic risk to regional security as well as some U.S. interests over the long run will be mass movements of refugees, and sometimes migrants, across borders. Demographically induced changes in conventional balances of power and interstate competition over renewable resources are less dangerous threats to U.S. strategic interests.

Demographics and Domestic Politics

Now that we have examined how demographic factors could change warfare and affect regional security, it is important to assess how demographic factors might affect the political nature of states and hence their foreign policies. Demographic shifts can affect domestic politics in four ways: the creation of revolutionary states, the creation of failed states, the outbreak of ethnic warfare, and the ecological marginalization of poorer socioeconomic groups.

Before proceeding, we should keep in mind that sheer population size does not usually lead to domestic disruptions in the developing world. Instead, it is primarily the skewing of the national age distribution in favor of younger citizens that often puts extreme pressure on the educational, health care, sanitation, and economic infrastructures of developing nations that is the most decisive factor creating domestic instability. Another set of variables that must not be forgotten here are those dealing with the evolving resource-consumption practices of the members of a given population, whether they are young or old. The environmental impacts of population growth can be greatly magnified by a population's changing perceptions of what constitutes "acceptable" resource availability and usage rates.[24] These perceptions, or ideational factors, are shaped and developed under the influence of a society's institutions, social relations, preferences, and beliefs.[25]

Another factor playing an increasing role here is large internal migrations within countries that have gross disparities in living conditions across different states or provinces. Today's China provides us a good example of this, as the emergence of a large population of floating migrant workers is burdening some major cities and raising fears of increasing social instability among China's Communist Party elite, especially as the prospect of a national economic downturn looms.

Revolutionary states. In high-fertility developing states that contain radical political movements on the fringes of their political spectra, the emergence of high structural unemployment at a time when the national age distribution is highly skewed in favor of 18- to 24-year-olds will often result in many of the youthful unemployed coming to support the radical political alternatives. If the elites in these radical political movements are able to accomplish an effective social mobilization of these youths, then a full-scale revolution may occur. Successful ideological revolutions such as these tend to result in states that often seek to spread messianic political messages by force to their neighbors. After all, revolutionary France morphed into Napoleon's Imperial France, revolutionary Iran supported a wide variety of Islamic terrorist organizations that preyed on its regional neighbors, and China lashed out at American forces in Korea very soon after the successful completion of its communist revolution. Even if the revolutionary state itself is not inherently aggressive, the sudden and dramatic change that it represents often worries its neighbors to the point that they will attempt to take military action to crush or at least weaken the new revolutionary state in its infancy. The destructive impacts of internal demographics in this case are clear and can often lead to severe international security problems.

Today, the purest case of this problem is seen in Algeria's bloody civil war between the Islamic Salvation Front and the secularist government.[26] Algeria has a rapidly growing population that will rise from 29.5 million in 1997 to 47.3 million in 2025.[27] The Algerian combination of large youth cohorts, high structural unemployment, and the existence of radical Islam as an alternative force for social mobilization has led to the current civil strife. Other states in the Islamic world that have fast-growing populations and structural unemployment or underemployment could also be at risk for increasing domestic instability. Egypt, a key U.S. ally in the Middle East, has some of the same elements at work that we see in Algeria; however, there is reason to believe that the situation there may be more hopeful over the long run, as Egyptian culture in general appears to be relatively unreceptive to radical fundamentalism in comparison to other Arab states. Also, Egypt's overall fertility rate is indeed lower than Algeria's (3.6 and 4.4 children per woman respectively), and it is conceivable that this lower rate could be at least partially attributable to the large amount of U.S. foreign aid that Egypt has been receiving.[28]

There is also some empirical academic work that provides evidence of linkages between demographic pressures and revolutions. Of particular relevance is the research of Jack Goldstone.[29] He shows that population growth in 18th century France did play a role in the coming of the French Revolution.[30] He does this by first showing that France's population grew from 24.6 million in 1740 to 28.1 million in 1790 and that from 1700 to 1780 France's population grew by roughly 30 percent.[31] More important than the absolute population growth, though, was the fact that the ratio of youth (people under 18) to adults increased significantly during roughly the same period--from 0.6 to 0.8.[32] This "youth bulge" helped to increase demand for food at a time of stagnant supply levels, driving up food prices throughout France. Inflation accelerated further as a result of the increasing size of urban areas in France, where the velocity of money was higher than in rural areas. The consequence of all of this was reduced purchasing power for the average French wage earner, which had the ripple effect of creating a business downturn for the growing and increasingly powerful French artisan and merchant classes. This situation led to the precursor conditions for social unrest--unrest that became even more likely when the outmoded land tax system maintained by the monarchy failed to provide enough revenue to support public spending, thus pointing France onto the path of eventual bankruptcy, which was officially declared in 1787.[33]

Failed states. In failed states, the basic infrastructure of governance has broken down, leaving anarchy in its wake. Political power in failed states is exercised not by conventional political regimes but by outlaw warlords using mercenary armies to control turf and relying on systems of corruption, smuggling, and patronage to finance themselves.[34] The U.S. intervention in Somalia in 1992 was a result of the failed-state phenomenon; the existing warlord networks were not supporting a food distribution system that could meet the needs of all of Somalia's people.

In the absence of sound government policies, continued high fertility in extremely poor, "Fourth World" agrarian societies that have recently seen their mortality rates reduced as a result of the introduction of modern medicine can result in explosive population growth that overwhelms the state infrastructure and exhausts croplands. The resulting mass rural-to-urban migrations often lead to political instability, crime waves, and the collapse of the central government. West Africa has been particularly susceptible to the failed-state phenomenon in the 1990s, with Sierra Leone and Liberia being two prime examples (nations with fertility rates of 6.1 and 6.3 respectively).[35] Failed states can foster humanitarian crises like famines, epidemics, or mass criminal violence that require international military intervention; such states can also serve as breeding grounds for narcotics trafficking and other international criminal activity.

Ethnic conflict. In states with ethnically intermixed patterns of population settlement, any significant loss of central government legitimacy or control, when coupled with the existence of nationalist history among one or more of the ethnic groups involved, can provide the spark needed to ignite a violent conflagration. Intermixed patterns of settlement contain within them an inherently greater risk of conflict than do situations in which a minority ethnic group is clearly concentrated within a well-defined geographical area. If central government authority begins to weaken in states with ethnically intermixed settlement patterns, there is a risk that the "security dilemma" may kick in.[36] This simply means that measures that one ethnic group takes to protect itself (e.g., village self-defense patrols, the stockpiling of small arms) could be perceived as offensive and threatening by the other group(s), who will then take countermeasures. The resulting spiral in preparations increases the risk of ethnic warfare, especially if the legitimacy of the national government continues to erode. If one of the ethnic groups involved has a faster-growing population than the other, then the effect of the security dilemma may become greatly magnified from the standpoint of the slower-growing group, creating additional incentives to accelerate preparations for violent conflict. Members of the slower-growing group may see themselves facing a closing "window of opportunity" after which the demographic dominance of the rival group will foreclose any option for asserting their claims to certain lands and/or political privileges.

This kind of demographic impact may have been one of the secondary causes of the ethnic strife that has plagued the former Yugoslavia during the past decade. Although Serb hypernationalism and the accompanying quest for a "Greater Serbia" on the part of Bosnian Serb leader Radovan Karadzic and Serbian President Slobodan Milosevic was the principal cause of the conflicts in Bosnia and Kosovo, the dynamics of differential population growth rates could well have served to fuel Serb feelings of insecurity that had been initially created by these demagogic leaders.

From the 1960s onward through the 1980s, Muslim population growth rates in Bosnia outstripped those of Serbs, as shown in Table 3.[37] This was due partially to fertility differentials and partially to an exodus of Serbian youth to urban areas in Serbia proper in search of economic opportunity. Over time, the increasing Muslim proportion of the total Bosnian population was translated into greater Muslim political, economic, and cultural clout at the expense of the previously dominant Serbs. As Tim Judah notes, "After 1966 Serbian dominance of the administration and the Bosnian communist party began to wane. Increasingly Bosnia's Muslims began to make themselves felt in the running of the republic and in the shaping of its future."[38] When the Yugoslav federal government began to unravel in 1991, the demographic realities in Bosnia may have helped to increase the receptiveness of ordinary Bosnian Serbs to the extremist rhetoric employed by their leaders and thus also their willingness to mobilize for military attacks against Muslim towns, villages, and farms.

Kosovo presents perhaps a clearer case of demographic shifts having political and security impacts against the backdrop of a dying state superstructure. Between 1948 and 1981, the Albanian proportion of the total Kosovo population rose from 69 percent to 77 percent as the Serb share dropped from 23 percent to 13 percent.[39] This shift was due mainly to very high Albanian fertility rates and not to any real decline in the absolute size of the Serb population in Kosovo. As federal Yugoslavia began to show signs of strain in the late 1980s, Serbs in Kosovo began to agitate more actively for Belgrade to offer them greater rights and protections in the face of growing Albanian control of the Kosovo regional administrative bureaucracy. This sense of grievance held by the Kosovo Serbs provided the key issue that Milosevic and his kindred Serb nationalists used to come to power within Serbia in the late 1980s and to begin to manipulate the ethnic tensions of the federation for their own political benefit, thus putting the country squarely on the road to civil war and disintegration.

In both Balkan cases, one can argue that differential population growth rates were perceived by the slower-growing group as creating conditions of closure that would allow the faster-growing ethnic group to steadily monopolize preferential access to various privileges and resources. Thus, the Serbs in each case may have come to believe (with a lot of help from the heated rhetoric of their demagogic leaders) that the increasing population proportions of the Bosnian Muslims and the Kosovar Albanians would permit these groups to "lock up" access to senior government and private-sector positions that would, in turn, ensure the institutionalization of preferential treatment for their kinfolk in day-to-day provincial life.

Bosnia and Kosovo are not by any means isolated examples of the dangers of demographic shifts in ethnically mixed environments. The history of conflicts in Lebanon and Northern Ireland supports the hypothesis formed on the basis of the Bosnian war. The Lebanese civil war of 1975-1990 began at a time when Shiite Muslim population growth was threatening Maronite Christian control over Lebanon's national political institutions. Northern Ireland's "time of troubles" between Protestants and Catholics began in the early 1970s, just as demographic trends in the province were swinging in favor of the Catholic minority.

Ethnic conflicts along these lines are especially dangerous security problems for outside powers to deal with because in some cases, as Chaim Kaufmann has shown, often the only long-term comprehensive solution that brings peace once full-scale ethnic war has broken out is a forcible

Citing a study that shows Middle American whites are dying in increasing numbers, like a twisted and bitter eugenicist, serial-plagiarist Fareed Zakaria doesn’t even attempt to contain his glee. By painting those who are supposedly dying as useless, drug-addicted ragers, he paints a picture of a weak, angry, and ultimately stupid ethnic group getting what it deserves.

If this were any other group, Zakaria would not be using the pages of the Washington Post for a victory dance. Instead, he would be launching an emotional blackmail campaign to cure this “epidemic” with hundreds of billions of federal dollars. Like most of the elite media, though, Zakaria despises Middle America, so he joyously assumes the study is accurate and bloodlessly screams “Told You So!”

Why is Middle America killing itself? The fact itself is probably the most important social science finding in years. It is already reshaping American politics. The Post’s Jeff Guo notes that the people who make up this cohort are “largely responsible for Donald Trump’s lead in the race for the Republican nomination for president.”

What does this “epidemic” mean to Zakaria?

That it’s time for compassion?

Time for government action?

Time for understanding?

No. It means “more rage” from creepy Middle America:

The key question is why, and exploring it provides answers that suggest that the rage dominating U.S. politics will only get worse.

Zakaria hints that the study’s numbers are a tad shaky, but that doesn’t stop him from doing a happy dance around the fact that…

Middle America’s Got It Coming….

The main causes of death are as striking as the fact itself: suicide, alcoholism, and overdoses of prescription and illegal drugs. “People seem to be killing themselves, slowly or quickly,” Deaton told me. These circumstances are usually caused by stress, depression and despair.

Middle America’s a Bunch of Wussies….

A conventional explanation for this middle-class stress and anxiety is that globalization and technological change have placed increasing pressures on the average worker in industrialized nations. But the trend is absent in any other Western country — it’s an exclusively American phenomenon. And the United States is actually relatively insulated from the pressures of globalization, having a vast, self-contained internal market.

Stupid Middle America Should Stop Voting Against the Welfare State…

Deaton speculated to me that perhaps Europe’s more generous welfare state might ease some of the fears associated with the rapid change.

Middle America’s Spoiled By White Privilege…

[O]ther groups might not expect that their income, standard of living and social status are destined to steadily improve. They don’t have the same confidence that if they work hard, they will surely get ahead. In fact, Rouse said that after hundreds of years of slavery, segregation and racism, blacks have developed ways to cope with disappointment and the unfairness of life[.]

They do not assume that the system is set up for them. They try hard and hope to succeed, but they do not expect it as the norm.

Donald Trump Can’t Save You!

Mwuh, huh, huh, huh…

Donald Trump has promised that he will change this and make them win again. But he can’t. No one can. And deep down, they know it.

Speaking only for myself, I’d rather die young in Middle America than as an old metrosexual, content-thieving, throne-sniffing, left-wing elitist so lacking in humanity that I not only gloat over racially-focused studies involving premature death, but like Joseph Goebbels, I openly spread the word that this is good news.

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A large segment of white middle-aged Americans has suffered a startling rise in its death rate since 1999, according to a review of statistics published Monday that shows a sharp reversal in decades of progress toward longer lives.

The mortality rate for white men and women ages 45-54 with less than a college education increased markedly between 1999 and 2013, most likely because of problems with legal and illegal drugs, alcohol and suicide, the researchers concluded. Before then, death rates for that group dropped steadily, and at a faster pace.

An increase in the mortality rate for any large demographic group in an advanced nation has been virtually unheard of in recent decades, with the exception of Russian men after the collapse of the Soviet Union.

The rising death rate was accompanied by an increase in the rate of illness, the authors wrote in the Proceedings of the National Academy of Sciences.

“Drugs and alcohol, and suicide . . . are clearly the proximate cause,” said Angus Deaton, the 2015 Nobel laureate in economics, who co-authored the paper with his wife, Anne Case. Both are economics professors at Princeton University.

“Half a million people are dead who should not be dead,” he added. “About 40 times the Ebola stats. You’re getting up there with HIV-AIDS.”

Death rate for U.S. non-Hispanic whites (USW), U.S. Hispanics and six comparison countries, aged 45-54. (Source: Proceedings of the National Academy of Sciences.)

Since at least 1970, Americans and residents of other wealthy countries have generally enjoyed longer and healthier lives, as smoking has declined, better treatments have been developed and preventive measures and lifestyle changes have had an impact.

But Monday’s bleak findings could have far-reaching implications as the surviving members of this sizable segment of the population continue toward retirement and eligibility for Medicare, according to experts. A sicker population that has been less able to prepare for the costs associated with old age will place an increasing burden on society and federal programs, they said.

“This is the first indicator that the plane has crashed,” said Jonathan Skinner, a professor of economics at Dartmouth College, who reviewed the study and co-authored a commentary that appears with it. “I don’t know what’s going on, but the plane has definitely crashed.

“High school graduates [and] high school dropouts [are] 40 percent of the population,” he added. “It’s not just the 10 percent who didn’t finish high school. It’s a much bigger group.”

Death rates for other developed nations examined by the two researchers, as well as rates for U.S. blacks and Hispanics, continued their steady decline of recent decades. Whites in other age groups between 30 and 64, and more educated whites also had lower death rates. But the other age groups also experienced substantially higher death rates from drug and alcohol overdoses, suicide, chronic liver disease and cirrhosis of the liver.

Mortality by cause among white non-Hispanics ages 45-54. (Source: Proceedings of the National Academy of Sciences.)

While the death rate for African Americans is still greater than the rate for whites, the turnaround among whites is shocking because of the advantages they enjoy, said David Weir, director of the health and retirement study at the Institute for Social Research at the University of Michigan.

Typically, socioeconomic circumstances “gang up on African Americans, who have lower education, lower incomes and race all working against them,” said Weir, who also reviewed the study for the journal. “In this case, that’s not happening.”

Weir said economic insecurity, the decay of communities and the breakdown of families probably have had some impact on death and illness rates, in addition to the nation’s opioid epidemic and the factors the authors identified. But the study clearly shows they are not the result of diseases such as lung cancer or diabetes, which are declining and increasing slowly, respectively.

Death by poisoning, suicide, chronic liver disease and cirrhosis for white non-Hispanics of varying age groups. (Source: Proceedings of the National Academy of Sciences.)

“I think it has to have something to do [with] the pain underlying it,” both physical and psychic, he said. “That is the age when people have their midlife crisis . . . I think it has to do with that stage of life, and physical ailments do start to accumulate at that age.

“This paper really is a question, not an answer,” he added.

Case and Deaton were examining government statistics on death rates and illness when they discovered the spike in mortality for people ages 45 to 54 in the period between 1999 and 2013.

“We both were sort of blown off our chairs when looking at that,” Deaton said. He said they knew that most demographers would look at the numbers and say, “ ‘You’ve got to have made a mistake. That cannot possibly be true.’ ”

When they pored over the data, however, they found that mortality rates for this group had risen an average of a half percent per year since 1999, after falling an average of 2 percent annually for the 20 years before that. If mortality rates group had stayed on their steady downward course, a half-million more people would be alive today, they determined.

When they looked at illness (morbidity), “there was a large and statistically significant decline in the fraction reporting excellent or very good health” that was matched by increased reports of physical pain, according to the study.

The proportion of people who said they were in “serious psychological distress” also rose significantly, the research shows.

Deaton, awarded the Nobel prize for his work on individual consumption choices, has long studied measures of well-being, health and pain. He and Case authored a paper in June that found reports of physical pain “are strongly predictive of suicide in many contexts” and that reports of pain are increasing among middle-aged Americans.

Their findings have been corroborated by other research. A report from the National Heroin Task Force established by the Justice Department puts the number of overdose deaths from legal and illegal drugs at 110 every day. The heroin death toll has quadrupled in the decade that ended in 2013, according to the Centers for Disease Control and Prevention.

A study in the journal JAMA Psychiatry last year reported that 90 percent of the people who tried heroin for the first time in the last decade were white. Three-quarters said they were introduced to heroin through the use of prescription drugs.

In January, the CDC reported that an average of six people die every day because of alcohol poisoning and that 76 percent are ages 35 to 64. Three-quarters are men.

But just last week, researchers reported that the U.S. death rate for all causes declined 43 percent between 1969 and 2013, from about 1,279 per 100,000 people to about 730. The rate of death caused by strokes, heart disease and cancer all declined significantly, researchers reported in the Journal of the American Medical Association.

STARTING around the turn of the millennium, the United States experienced the most alarming change in mortality rates since the AIDS epidemic. This shift was caused, not by some dreadful new disease, but by drugs and alcohol and suicide — and it was concentrated among less-educated, late-middle-aged whites.

We had hints that something like this was happening. We knew suicide was increasing among the middle-aged, that white women without a high school degree were struggling with health issues, that opiate addiction was a plague in working-class communities. But we didn’t know it was all bad enough to send white death rates modestly upward in the richest nation in the world.

Now we know, thanks to a new paper from the Nobel laureate Angus Deaton and his wife, Anne Case. And their findings, inevitably, are the latest ideological Rorschach test in the debate over how to save the American working class.

To many conservatives, the mortality rate shock is the latest indictment of modern liberalism’s mix of moral permissiveness and welfare-state paternalism: The first undercuts the rootedness, discipline and purpose that marriage and religion once supplied, and the latter eases people into a life ofdependence and disability payments that only encourages drug abuse and suicidal thoughts.

But if the problem is social liberalism and the welfare state, progressives object, then why is the working class death rate only rising starkly in the United States? In the more secular and socialist territory of the European Union, Deaton and Case are at pains to note, white mortality rates have continued to decline.

This buttresses the longstanding liberal argument that the American working class has fallen victim, not to dependency and libertinism, but to a punishing economic climate — stagnant wages, a fraying safety net, and Republican economic policies that redistribute wealth upward. Hence the European contrast: If we had the same institutions as France and Germany, our working class might still be struggling, but at least it would be protected from immiseration and despair.

Yet here, too, Deaton and Case’s data is somewhat confounding, because if economic stress were all, you would expect the mortality crisis to manifest itself more sharply among black and Hispanic Americans — who have consistently higher unemployment rates than their white neighbors, and lag whites in wealth by far.

But in fact the mortality rate for minorities in the U.S. continued to fall between 1999 and 2013, mirroring the trend in Europe, and the African-American death rate in particular fell hugely. Amid the stresses of the dot-com bust and the Great Recession, it was only white Americans who turned increasingly to drugs, liquor and quietus.

Why only them? One possible solution is suggested by a paper from 2012, whose co-authors include Andrew Cherlin and Brad Wilcox, leading left and right-leaning scholars, respectively, of marriage and family.

Noting that religious practice has fallen faster recently among less-educated whites than among less-educated blacks and Hispanics, their paper argues that white social institutions, blue-collar as well as white-collar, have long reflected a “bourgeois moral logic” that binds employment, churchgoing, the nuclear family and upward mobility.

But in an era of stagnating wages, family breakdown, and social dislocation, this logic no longer seems to make as much sense. The result is a mounting feeling of what the American Conservative’sRod Dreher calls white “dispossession” — a sense of promises broken, a feeling that what you were supposed to have has been denied to you. (The Donald Trump phenomenon, Dreher notes, feeds off precisely this anxiety.)

For obvious historical reasons, though, Hispanic and (especially) black communities have cultivated a different set of expectations, a different model of community and family (more extended and matriarchal), a different view of success and the American story writ large.

These distinctives come with their own set of problems, particularly where family structure and fatherhood are concerned. But they may create a kind of resilience, a capacity for dealing with stagnation and disappointment (and elite indifference or hostility), which many working-class white Americans did not necessarily expect to ever need.

If this possibility has policy implications, it suggests that liberals are right to emphasize the economic component to the working class’s crisis. But it cautions against the idea that transfer payments can substitute for the sense of meaning and purpose that blue-collar white Americans derived from the nexus of work, faith and family until very recently.

Maybe sustained growth, full employment and a welfare state that’s friendlier to work and family can help revive that nexus. Or maybe working-class white America needs to adapt culturally, in various ways, to this era of relative stagnation, and learn from the resilience of communities that are used to struggling in the shadow of elite neglect.

Or maybe it will take a little bit of both, more money and new paths to resilience alike, to make some of the unhappiest white lives feel like they matter once again.

Deaton, an economics professor at Princeton, was talking about the stunning finding that he and his wife, Anne Case, made while analyzing U.S. death data from the past few decades. The researchers found that the mortality rate for white men and women ages 45 to 54 with less than a college education took a sharp turn upward in 1999 — a disconcerting reversal that has been virtually unheard of in advanced countries.

To put that number into perspective, Deaton estimates that a half-million deaths is "about 40 times the Ebola stats." He added, "You’re getting up there with HIV-AIDS."

The couple's study, which was published in the Proceedings of the National Academy of Sciences this week, offered a number of possible reasons that this might be happening. And since its publication, other experts have weighed in on other trends that might explain this phenomenon. Below is a look at five of their theories. Many of them have to do more with psychological distress than traditional causes of death such as heart disease or lung cancer.

1. The nation's opioid epidemic. "Deaths from drug overdoses among people aged 45 through 64 increased 11-fold between 1990 and 2010, and nearly 90 percent of people who try heroin for the first time these days are white," the Atlantic noted. Washington County in Pennsylvania, for instance, logged eight overdoses in 70 minutes earlier this year. There have been more than 50 fatal overdoses this year.

2. Alcohol poisoning. More than 2,200 Americans die a year after consuming too much alcohol and three-fourths are ages 35 to 64, according to the Centers for Disease Control and Prevention. According to the Daily Mail, "While death rates related to drugs, alcohol and suicides have risen for middle-aged whites across the board, the largest surge are seen among those with the least education. For those with a high school degree or less, deaths caused by drug and alcohol poisoning rose four fold, suicides increased by 81 per cent, and deaths caused by liver disease and cirrhosis jumped 50 per cent."

3. Suicide. The Case-Deaton study noted that poisonings overtook lung cancer as a leading cause of death in 2011 in this age group and that suicide rates were headed in that direction, as well.

4. The end of the American dream? With the disappearance of stable jobs in manufacturing and construction over the years, many people with only a high school education may not have as many opportunities as they may have had a generation ago. Surveys have shown that about half of middle-aged Americans have not been able to save enough money for retirement. Many in this generation are "the first to find, in midlife, that they will not be better off than their parents," the authors wrote.

5. Breakdown of family support networks. The divorce rate among those over age 50 has doubled — to one out of every four people — at a time when divorce rates for other age groups have stabilized or dropped. In a new book about white America, Charles Murray shows how "marriage has become the fault line dividing America's classes." As compared with the white working class, the white affluent divorce less, report that they have happier marriages and raise fewer children as single parents, according to the New Republic.